Niagara Health System · Qmentum accreditation program. As part of this ongoing process of quality improvement, an on-site survey was conducted in November 2015. Information from

Accreditation Report

Niagara Health System

On-site survey dates: November 22, 2015 - November 27, 2015

Accredited by ISQua

St. Catharines, ON

Report issued: March 7, 2016

Confidentiality

This report is confidential and is provided by Accreditation Canada to the organization only. Accreditation Canadadoes not release the report to any other parties.

In the interests of transparency and accountability, Accreditation Canada encourages the organization todisseminate its Accreditation Report to staff, board members, clients, the community, and other stakeholders.

Any alteration of this Accreditation Report compromises the integrity of the accreditation process and is strictlyprohibited.

About the Accreditation Report

Niagara Health System (referred to in this report as “the organization”) is participating in Accreditation Canada'sQmentum accreditation program. As part of this ongoing process of quality improvement, an on-site survey wasconducted in November 2015. Information from the on-site survey as well as other data obtained from theorganization were used to produce this Accreditation Report.

Accreditation results are based on information provided by the organization. Accreditation Canada relies on theaccuracy of this information to plan and conduct the on-site survey and produce the Accreditation Report.

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© Accreditation Canada, 2016

A Message from Accreditation Canada's President and CEO

On behalf of Accreditation Canada's board and staff, I extend my sincerest congratulations to your board, yourleadership team, and everyone at your organization on your participation in the Qmentum accreditation program.Qmentum is designed to integrate with your quality improvement program. By using Qmentum to support andenable your quality improvement activities, its full value is realized.

This Accreditation Report includes your accreditation decision, the final results from your recent on-site survey,and the instrument data that your organization has submitted. Please use the information in this report and inyour online Quality Performance Roadmap to guide your quality improvement activities.

Your Accreditation Specialist is available if you have questions or need guidance.

Thank you for your leadership and for demonstrating your ongoing commitment to quality by integratingaccreditation into your improvement program. We welcome your feedback about how we can continue tostrengthen the program to ensure it remains relevant to you and your services.

We look forward to our continued partnership.

Sincerely,

Wendy NicklinPresident and Chief Executive Officer

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A Message from Accreditation Canada's President and CEO

Table of Contents

1.0 Executive Summary 1

1.1 Accreditation Decision 1

1.2 About the On-site Survey 2

1.3 Overview by Quality Dimensions 4

1.4 Overview by Standards 5

1.5 Overview by Required Organizational Practices 7

1.6 Summary of Surveyor Team Observations 15

2.0 Detailed Required Organizational Practices Results 17

3.0 Detailed On-site Survey Results 18

3.1 Priority Process Results for System-wide Standards 19

3.1.1 Priority Process: Governance 19

3.1.2 Priority Process: Planning and Service Design 21

3.1.3 Priority Process: Resource Management 22

3.1.4 Priority Process: Human Capital 23

3.1.5 Priority Process: Integrated Quality Management 25

3.1.6 Priority Process: Principle-based Care and Decision Making 27

3.1.7 Priority Process: Communication 28

3.1.8 Priority Process: Physical Environment 29

3.1.9 Priority Process: Emergency Preparedness 30

3.1.10 Priority Process: Patient Flow 32

3.1.11 Priority Process: Medical Devices and Equipment 34

3.2 Service Excellence Standards Results 36

3.2 Service Excellence Standards Results 37

3.2.1 Standards Set: Ambulatory Systemic Cancer Therapy Services - Direct Service Provision 37

3.2.2 Standards Set: Biomedical Laboratory Services - Direct Service Provision 40

3.2.3 Standards Set: Cancer Care and Oncology Services - Direct Service Provision 41

3.2.4 Standards Set: Critical Care - Direct Service Provision 43

3.2.5 Standards Set: Diagnostic Imaging Services - Direct Service Provision 46

3.2.6 Standards Set: Emergency Department - Direct Service Provision 47

3.2.7 Standards Set: Infection Prevention and Control Standards - Direct Service Provision 51

3.2.8 Standards Set: Long-Term Care Services - Direct Service Provision 53

3.2.9 Standards Set: Medication Management Standards - Direct Service Provision 55

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iTable of ContentsAccreditation Report

3.2.10 Standards Set: Medicine Services - Direct Service Provision 57

3.2.11 Standards Set: Mental Health Services - Direct Service Provision 60

3.2.12 Standards Set: Obstetrics Services - Direct Service Provision 62

3.2.13 Standards Set: Organ and Tissue Donation Standards for Deceased Donors - DirectService Provision

65

3.2.14 Standards Set: Point-of-Care Testing - Direct Service Provision 67

3.2.15 Standards Set: Substance Abuse and Problem Gambling Services - Direct ServiceProvision

68

3.2.16 Standards Set: Transfusion Services - Direct Service Provision 70

3.2.17 Priority Process: Surgical Procedures 71

4.0 Instrument Results 73

4.1 Governance Functioning Tool 73

4.2 Canadian Patient Safety Culture Survey Tool 77

4.3 Worklife Pulse 79

4.4 Client Experience Tool 80

Appendix A Qmentum 81

Appendix B Priority Processes 82

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iiTable of ContentsAccreditation Report

Niagara Health System (referred to in this report as “the organization”) is participating in Accreditation Canada'sQmentum accreditation program. Accreditation Canada is an independent, not-for-profit organization that setsstandards for quality and safety in health care and accredits health organizations in Canada and around theworld.

As part of the Qmentum accreditation program, the organization has undergone a rigorous evaluation process.Following a comprehensive self-assessment, external peer surveyors conducted an on-site survey during whichthey assessed this organization's leadership, governance, clinical programs and services against AccreditationCanada requirements for quality and safety. These requirements include national standards of excellence;required safety practices to reduce potential harm; and questionnaires to assess the work environment, patientsafety culture, governance functioning and client experience. Results from all of these components are includedin this report and were considered in the accreditation decision.

This report shows the results to date and is provided to guide the organization as it continues to incorporate theprinciples of accreditation and quality improvement into its programs, policies, and practices.

The organization is commended on its commitment to using accreditation to improve the quality and safety of theservices it offers to its clients and its community.

1.1 Accreditation Decision

Niagara Health System's accreditation decision is:

Accredited with Exemplary Standing

The organization has attained the highest level of performance, achieving excellence in meeting therequirements of the accreditation program.

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Executive SummarySection 1

Executive Summary 1Accreditation Report

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1.2 About the On-site Survey

• On-site survey dates: November 22, 2015 to November 27, 2015

• Locations

The following locations were assessed during the on-site survey. All sites and services offered by theorganization are deemed accredited.

1 Douglas Memorial Hospital

2 Greater Niagara General Hospital

3 Port Colborne General Hospital

4 St. Catharines Hospital Site

5 Welland Hospital

• Standards

The following sets of standards were used to assess the organization's programs and services during theon-site survey.

System-Wide Standards

Leadership1

Governance2

Medication Management Standards3

Infection Prevention and Control Standards4

Service Excellence Standards

Cancer Care and Oncology Services - Service Excellence Standards5

Reprocessing and Sterilization of Reusable Medical Devices - Service ExcellenceStandards

6

Organ and Tissue Donation Standards for Deceased Donors - Service ExcellenceStandards

7

Critical Care - Service Excellence Standards8

Point-of-Care Testing - Service Excellence Standards9

Diagnostic Imaging Services - Service Excellence Standards10

Medicine Services - Service Excellence Standards11

Substance Abuse and Problem Gambling Services - Service Excellence Standards12

Ambulatory Systemic Cancer Therapy Services - Service Excellence Standards13

Obstetrics Services - Service Excellence Standards14

Mental Health Services - Service Excellence Standards15

Transfusion Services - Service Excellence Standards16

Biomedical Laboratory Services - Service Excellence Standards17


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Perioperative Services and Invasive Procedures Standards - Service ExcellenceStandards

18

Long-Term Care Services - Service Excellence Standards19

Emergency Department - Service Excellence Standards20

• Instruments

The organization administered:

Governance Functioning Tool1

Canadian Patient Safety Culture Survey Tool2

Worklife Pulse

4 Client Experience Tool

3


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1.3 Overview by Quality Dimensions

Accreditation Canada defines quality in health care using eight dimensions that represent key service elements.Each criterion in the standards is associated with a quality dimension. This table shows the number of criteriarelated to each dimension that were rated as met, unmet, or not applicable.

Quality Dimension Met Unmet N/A Total

Population Focus (Work with my community toanticipate and meet our needs) 75 0 0 75

Accessibility (Give me timely and equitableservices) 101 0 0 101

Safety (Keep me safe)702 6 19 727

Worklife (Take care of those who take care of me)166 2 2 170

Client-centred Services (Partner with me and myfamily in our care) 258 2 3 263

Continuity of Services (Coordinate my care acrossthe continuum) 80 0 2 82

Appropriateness (Do the right thing to achieve thebest results) 1074 12 12 1098

Efficiency (Make the best use of resources)79 1 0 80

Total 2535 23 38 2596


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1.4 Overview by Standards

The Qmentum standards identify policies and practices that contribute to high quality, safe, and effectivelymanaged care. Each standard has associated criteria that are used to measure the organization's compliance withthe standard.

System-wide standards address quality and safety at the organizational level in areas such as governance andleadership. Population-specific and service excellence standards address specific populations, sectors, andservices. The standards used to assess an organization's programs are based on the type of services it provides.

This table shows the sets of standards used to evaluate the organization's programs and services, and the numberand percentage of criteria that were rated met, unmet, or not applicable during the on-site survey.

Accreditation decisions are based on compliance with standards. Percent compliance is calculated to the decimaland not rounded.

Standards SetMet Unmet N/A

High Priority Criteria *

# (%) # (%) #

Met Unmet N/A

Other Criteria

# (%) # (%) #

Met Unmet N/A

Total Criteria(High Priority + Other)

# (%) # (%) #

Governance 42(100.0%)

0(0.0%)

0 31(96.9%)

1(3.1%)

0 73(98.6%)

1(1.4%)

0

Leadership 43(93.5%)

3(6.5%)

0 82(96.5%)

3(3.5%)

0 125(95.4%)

6(4.6%)

0

Infection Preventionand Control Standards

41(100.0%)

0(0.0%)

0 27(93.1%)

2(6.9%)

2 68(97.1%)

2(2.9%)

2

MedicationManagementStandards

68(98.6%)

1(1.4%)

9 59(98.3%)

1(1.7%)

4 127(98.4%)

2(1.6%)

13

Ambulatory SystemicCancer TherapyServices

49(100.0%)

0(0.0%)

1 98(100.0%)

0(0.0%)

1 147(100.0%)

0(0.0%)

2

Biomedical LaboratoryServices **

68(100.0%)

0(0.0%)

3 103(100.0%)

0(0.0%)

0 171(100.0%)

0(0.0%)

3

Cancer Care andOncology Services

33(100.0%)

0(0.0%)

0 74(98.7%)

1(1.3%)

1 107(99.1%)

1(0.9%)

1

Critical Care 34(100.0%)

0(0.0%)

0 95(100.0%)

0(0.0%)

0 129(100.0%)

0(0.0%)

0

Diagnostic ImagingServices

64(97.0%)

2(3.0%)

1 67(100.0%)

0(0.0%)

1 131(98.5%)

2(1.5%)

2


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Standards SetMet Unmet N/A

High Priority Criteria *

# (%) # (%) #

Met Unmet N/A

Other Criteria

# (%) # (%) #

Met Unmet N/A

Total Criteria(High Priority + Other)

# (%) # (%) #

EmergencyDepartment

47(100.0%)

0(0.0%)

0 80(100.0%)

0(0.0%)

0 127(100.0%)

0(0.0%)

0

Long-Term CareServices

39(100.0%)

0(0.0%)

1 89(98.9%)

1(1.1%)

4 128(99.2%)

1(0.8%)

5

Medicine Services 31(100.0%)

0(0.0%)

0 70(98.6%)

1(1.4%)

0 101(99.0%)

1(1.0%)

0

Mental Health Services 36(100.0%)

0(0.0%)

0 88(100.0%)

0(0.0%)

0 124(100.0%)

0(0.0%)

0

Obstetrics Services 64(100.0%)

0(0.0%)

0 79(98.8%)

1(1.3%)

0 143(99.3%)

1(0.7%)

0

Organ and TissueDonation Standards forDeceased Donors

39(100.0%)

0(0.0%)

0 80(100.0%)

0(0.0%)

0 119(100.0%)

0(0.0%)

0

Perioperative Servicesand InvasiveProcedures Standards

100(100.0%)

0(0.0%)

0 86(97.7%)

2(2.3%)

0 186(98.9%)

2(1.1%)

0

Point-of-Care Testing**

38(100.0%)

0(0.0%)

0 48(100.0%)

0(0.0%)

0 86(100.0%)

0(0.0%)

0

Reprocessing andSterilization ofReusable MedicalDevices

52(100.0%)

0(0.0%)

1 61(100.0%)

0(0.0%)

2 113(100.0%)

0(0.0%)

3

Substance Abuse andProblem GamblingServices

30(100.0%)

0(0.0%)

1 73(100.0%)

0(0.0%)

0 103(100.0%)

0(0.0%)

1

Transfusion Services ** 70(100.0%)

0(0.0%)

5 66(100.0%)

0(0.0%)

1 136(100.0%)

0(0.0%)

6

988(99.4%)

6(0.6%)

22 1456(99.1%)

13(0.9%)

16 2444(99.2%)

19(0.8%)

38Total

* Does not includes ROP (Required Organizational Practices)** Some criteria within this standards set were pre-rated based on the organization’s accreditation through the Ontario LaboratoryAccreditation Quality Management Program-Laboratory Services (QMP-LS).


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1.5 Overview by Required Organizational Practices

A Required Organizational Practice (ROP) is an essential practice that an organization must have in place toenhance client safety and minimize risk. Each ROP has associated tests for compliance, categorized as major andminor. All tests for compliance must be met for the ROP as a whole to be rated as met.

This table shows the ratings of the applicable ROPs.

Required Organizational Practice Overall rating Test for Compliance Rating

Major Met Minor Met

Patient Safety Goal Area: Safety Culture

Accountability for Quality(Governance)

Met 4 of 4 2 of 2

Adverse Events Disclosure(Leadership)

Met 3 of 3 0 of 0

Adverse Events Reporting(Leadership)

Met 1 of 1 1 of 1

Client Safety Quarterly Reports(Leadership)

Met 1 of 1 2 of 2

Client Safety Related-Prospective Analysis(Leadership)

Met 1 of 1 1 of 1

Patient Safety Goal Area: Communication

Client and Family Role in Safety(Ambulatory Systemic Cancer TherapyServices)

Met 2 of 2 0 of 0

Client and Family Role in Safety(Cancer Care and Oncology Services)

Met 2 of 2 0 of 0

Client and Family Role in Safety(Critical Care)

Met 2 of 2 0 of 0

Client and Family Role in Safety(Diagnostic Imaging Services)

Met 2 of 2 0 of 0

Client and Family Role in Safety(Long-Term Care Services)

Met 2 of 2 0 of 0

Client and Family Role in Safety(Medicine Services)

Met 2 of 2 0 of 0


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Major Met Minor Met


Client and Family Role in Safety(Mental Health Services)

Met 2 of 2 0 of 0

Client and Family Role in Safety(Obstetrics Services)

Met 2 of 2 0 of 0

Client and Family Role in Safety(Perioperative Services and InvasiveProcedures Standards)

Met 2 of 2 0 of 0

Client and Family Role in Safety(Substance Abuse and Problem GamblingServices)

Met 2 of 2 0 of 0

Information Transfer(Ambulatory Systemic Cancer TherapyServices)

Met 2 of 2 0 of 0

Information Transfer(Cancer Care and Oncology Services)

Met 2 of 2 0 of 0

Information Transfer(Critical Care)

Met 2 of 2 0 of 0

Information Transfer(Emergency Department)

Met 2 of 2 0 of 0

Information Transfer(Long-Term Care Services)

Met 2 of 2 0 of 0

Information Transfer(Medicine Services)

Met 2 of 2 0 of 0

Information Transfer(Mental Health Services)

Met 2 of 2 0 of 0

Information Transfer(Obstetrics Services)

Met 2 of 2 0 of 0

Information Transfer(Perioperative Services and InvasiveProcedures Standards)

Met 2 of 2 0 of 0


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Major Met Minor Met


Information Transfer(Substance Abuse and Problem GamblingServices)

Met 2 of 2 0 of 0

Medication reconciliation as a strategicpriority(Leadership)

Met 4 of 4 2 of 2

Medication reconciliation at caretransitions(Ambulatory Systemic Cancer TherapyServices)

Unmet 2 of 7 0 of 0

Medication reconciliation at caretransitions(Cancer Care and Oncology Services)

Met 5 of 5 0 of 0

Medication reconciliation at caretransitions(Critical Care)

Unmet 4 of 5 0 of 0

Medication reconciliation at caretransitions(Emergency Department)

Met 5 of 5 0 of 0

Medication reconciliation at caretransitions(Long-Term Care Services)

Met 5 of 5 0 of 0

Medication reconciliation at caretransitions(Medicine Services)

Unmet 3 of 5 0 of 0

Medication reconciliation at caretransitions(Mental Health Services)

Met 5 of 5 0 of 0

Medication reconciliation at caretransitions(Obstetrics Services)

Unmet 3 of 5 0 of 0


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Major Met Minor Met


Medication reconciliation at caretransitions(Perioperative Services and InvasiveProcedures Standards)

Met 5 of 5 0 of 0

Medication reconciliation at caretransitions(Substance Abuse and Problem GamblingServices)

Met 3 of 3 2 of 2

Safe Surgery Checklist(Obstetrics Services)

Met 3 of 3 2 of 2

Safe Surgery Checklist(Perioperative Services and InvasiveProcedures Standards)

Met 3 of 3 2 of 2

The “Do Not Use” list of abbreviations(Medication Management Standards)

Met 4 of 4 3 of 3

Two Client Identifiers(Ambulatory Systemic Cancer TherapyServices)

Met 1 of 1 0 of 0

Two Client Identifiers(Biomedical Laboratory Services)

Met 1 of 1 0 of 0

Two Client Identifiers(Cancer Care and Oncology Services)

Met 1 of 1 0 of 0

Two Client Identifiers(Critical Care)

Met 1 of 1 0 of 0

Two Client Identifiers(Diagnostic Imaging Services)

Met 1 of 1 0 of 0

Two Client Identifiers(Emergency Department)

Met 1 of 1 0 of 0

Two Client Identifiers(Long-Term Care Services)

Met 1 of 1 0 of 0

Two Client Identifiers(Medicine Services)

Met 1 of 1 0 of 0


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Major Met Minor Met


Two Client Identifiers(Mental Health Services)

Met 1 of 1 0 of 0

Two Client Identifiers(Obstetrics Services)

Met 1 of 1 0 of 0

Two Client Identifiers(Perioperative Services and InvasiveProcedures Standards)

Met 1 of 1 0 of 0

Two Client Identifiers(Point-of-Care Testing)

Met 1 of 1 0 of 0

Two Client Identifiers(Substance Abuse and Problem GamblingServices)

Met 1 of 1 0 of 0

Two Client Identifiers(Transfusion Services)

Met 1 of 1 0 of 0

Patient Safety Goal Area: Medication Use

Antimicrobial Stewardship(Medication Management Standards)

Met 4 of 4 1 of 1

Concentrated Electrolytes(Medication Management Standards)

Met 3 of 3 0 of 0

Heparin Safety(Medication Management Standards)

Met 4 of 4 0 of 0

High-Alert Medications(Medication Management Standards)

Met 5 of 5 3 of 3

Infusion Pumps Training(Ambulatory Systemic Cancer TherapyServices)

Met 1 of 1 0 of 0

Infusion Pumps Training(Cancer Care and Oncology Services)

Met 1 of 1 0 of 0

Infusion Pumps Training(Critical Care)

Met 1 of 1 0 of 0


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Major Met Minor Met

Patient Safety Goal Area: Medication Use

Infusion Pumps Training(Emergency Department)

Met 1 of 1 0 of 0

Infusion Pumps Training(Long-Term Care Services)

Met 1 of 1 0 of 0

Infusion Pumps Training(Medicine Services)

Met 1 of 1 0 of 0

Infusion Pumps Training(Mental Health Services)

Met 1 of 1 0 of 0

Infusion Pumps Training(Obstetrics Services)

Met 1 of 1 0 of 0

Infusion Pumps Training(Perioperative Services and InvasiveProcedures Standards)

Met 1 of 1 0 of 0

Narcotics Safety(Medication Management Standards)

Met 3 of 3 0 of 0

Patient Safety Goal Area: Worklife/Workforce

Client Flow(Leadership)

Met 7 of 7 1 of 1

Client Safety Plan(Leadership)

Met 2 of 2 2 of 2

Client Safety: Education and Training(Leadership)

Met 1 of 1 0 of 0

Preventive Maintenance Program(Leadership)

Met 3 of 3 1 of 1

Workplace Violence Prevention(Leadership)

Met 5 of 5 3 of 3

Patient Safety Goal Area: Infection Control

Hand-Hygiene Compliance(Infection Prevention and ControlStandards)

Met 1 of 1 2 of 2


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Major Met Minor Met

Patient Safety Goal Area: Infection Control

Hand-Hygiene Education and Training(Infection Prevention and ControlStandards)

Met 1 of 1 0 of 0

Infection Rates(Infection Prevention and ControlStandards)

Met 1 of 1 2 of 2

Pneumococcal Vaccine(Long-Term Care Services)

Met 2 of 2 0 of 0

Patient Safety Goal Area: Risk Assessment

Falls Prevention Strategy(Ambulatory Systemic Cancer TherapyServices)

Met 3 of 3 2 of 2

Falls Prevention Strategy(Cancer Care and Oncology Services)

Met 3 of 3 2 of 2

Falls Prevention Strategy(Diagnostic Imaging Services)

Met 3 of 3 2 of 2

Falls Prevention Strategy(Emergency Department)

Met 3 of 3 2 of 2

Falls Prevention Strategy(Long-Term Care Services)

Met 3 of 3 2 of 2

Falls Prevention Strategy(Medicine Services)

Met 3 of 3 2 of 2

Falls Prevention Strategy(Mental Health Services)

Met 3 of 3 2 of 2

Falls Prevention Strategy(Obstetrics Services)

Met 3 of 3 2 of 2

Falls Prevention Strategy(Perioperative Services and InvasiveProcedures Standards)

Met 3 of 3 2 of 2

Pressure Ulcer Prevention(Cancer Care and Oncology Services)

Met 3 of 3 2 of 2


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Major Met Minor Met

Patient Safety Goal Area: Risk Assessment

Pressure Ulcer Prevention(Critical Care)

Met 3 of 3 2 of 2

Pressure Ulcer Prevention(Long-Term Care Services)

Met 3 of 3 2 of 2

Pressure Ulcer Prevention(Medicine Services)

Met 3 of 3 2 of 2

Pressure Ulcer Prevention(Perioperative Services and InvasiveProcedures Standards)

Met 3 of 3 2 of 2

Suicide Prevention(Mental Health Services)

Met 5 of 5 0 of 0

Venous Thromboembolism Prophylaxis(Cancer Care and Oncology Services)

Met 2 of 2 2 of 2

Venous Thromboembolism Prophylaxis(Critical Care)

Met 3 of 3 2 of 2

Venous Thromboembolism Prophylaxis(Medicine Services)

Met 3 of 3 2 of 2

Venous Thromboembolism Prophylaxis(Perioperative Services and InvasiveProcedures Standards)

Met 3 of 3 2 of 2


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The surveyor team made the following observations about the organization's overall strengths,opportunities for improvement, and challenges.

1.6 Summary of Surveyor Team Observations

The organization, Niagara Health System is commended on preparing for and participating in the Qmentumsurvey program. The Niagara Health System (NHS) has worked extremely hard in order to invest in quality andsafety of care, and plan for a better future. Participating in the Accreditation Canada process demonstrates thiscommitment to the organization. The various sites can celebrate many successes in their work, making theaccreditation process comprehensive and welcoming the surveyor team. In addition to having the opportunity tomeet with a range of internal and external stakeholders during the survey, the surveyors were provided withwritten, verbal and visual evidence to confirm compliance with the standards. Staff members and clients madethemselves readily available to answer questions and to demonstrate their skills and knowledge.

Since the organization's previous survey, the NHS has a new board and president and they are ensuring the needsof the community are met currently and most importantly, for the future. The community is beginning to see thebenefit in the closure of smaller community hospitals in order to build new facilities. This restructuring is criticalfor consolidating medical expertise and creating a critical mass to ensure competency and therefore, theprovision of safer quality care to patients. While this work commenced with a government-appointed supervisor,everyone is commended for seeing the vision through to fruition.

The board is instrumental in ensuring that oversight and direction are provided to the NHS. A favourablefinancial position has meant opportunities to attract and retain key clinical and administrative positions as wellas consolidate and open new programs and services. The organization is now building on the supervisor’s report,moving forward with strategic planning and capital planning and clinical visioning exercises.

The Niagara Health System is aware of the challenges it faces with aging infrastructure of some “vintage” sites,and an undefined time line for the proposed south site build and occupancy. As well, there are technologicalneeds to address going forward. Despite operating budgets being favourable, there is a significant workingcapital deficit and an aging population with increasing chronic diseases requiring greater robust primary care.

The surveyor team met with community partners from a range of services, academic institutions and the region,and they indicate that NHS is sharing, consultative, understanding and building a truly collaborative approach inworking together. Partners across the Niagara region indicate that there is more seamless integration than everbefore and according to them: “in 30 years, this is the best team to work with.” There are exciting examples ofincreased academic teaching opportunities and innovative approaches to ensuring services for the people ofNiagara, while building capacity for future care providers and health researchers.

The community partners would like NHS to know them better and potentially collaborate even more for someneeded services. For academic purposes, there is a desire to implement 'HSPnet' for monitoring clinicalplacement for various health disciplines. There is hope that the strong partnerships at the leadership levels willfilter to the front line, and that the changes that have occurred and are still to come, stay on track. There ishope also, that the ethics lens is applied regularly to all circumstances where applicable to support decisionmaking. There is the perception that NHS has: “come out of the dark and into the light.”

The leadership is committed to quality and safety as evidenced in the standardization and consolidation ofservices. There are improvements in emergency department (ED) wait times, and being responsive clinically viastrategies like critical care response teams, and administratively with huddle board discussions and rhythmrounds. The NHS is comprised of more than 5,000 staff members and physicians, 850 volunteers, and residentsand students in various health disciplines. The NHS has seen an improvement in staff engagement and reputationby measuring staff worklife and seeing an increased commitment and desire to work in the NHS. Recruitmentand retention have been enhanced as a result of the positive changes and opening of the new facility of St.Catharines General Hospital.

The delivery of care and services is foremost in everyone’s mind, with a focus on patient safety usingAccreditation Canada's required organizational practices to drive key safety elements across the NHS. The roadmap: “Route NHS” is used to create engagement and understanding of the accreditation process, and safetyrequirements is an example of innovation to which staff members have positively responded. Of benefit to thepatient and family is a white board called My Space, which is placed at each bedside. Also of benefit are thehuddle boards with NHS goals, indicators and safety data, and these are placed in hallways to be partners insafety and quality with care givers.

Patients and family members reported high levels of satisfaction during the survey visit. They described thelittle things that make a big difference like having the 'TLC' volunteers at the front entrance of the hospital.They spoke of the confidence they had in their care givers and noted the focus on safe, quality clinical care.Patients have nominated staff members for 'star awards of excellence' and during this on-site survey it was apleasure to meet those stars in action.


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by measuring staff worklife and seeing an increased commitment and desire to work in the NHS. Recruitmentand retention have been enhanced as a result of the positive changes and opening of the new facility of St.Catharines General Hospital.

The delivery of care and services is foremost in everyone’s mind, with a focus on patient safety usingAccreditation Canada's required organizational practices to drive key safety elements across the NHS. The roadmap: “Route NHS” is used to create engagement and understanding of the accreditation process, and safetyrequirements is an example of innovation to which staff members have positively responded. Of benefit to thepatient and family is a white board called My Space, which is placed at each bedside. Also of benefit are thehuddle boards with NHS goals, indicators and safety data, and these are placed in hallways to be partners insafety and quality with care givers.

Patients and family members reported high levels of satisfaction during the survey visit. They described thelittle things that make a big difference like having the 'TLC' volunteers at the front entrance of the hospital.They spoke of the confidence they had in their care givers and noted the focus on safe, quality clinical care.Patients have nominated staff members for 'star awards of excellence' and during this on-site survey it was apleasure to meet those stars in action.


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Detailed Required Organizational Practices ResultsSection 2

Each ROP is associated with one of the following patient safety goal areas: safety culture, communication,medication use, worklife/workforce, infection control, or risk assessment.

This table shows each unmet ROP, the associated patient safety goal, and the set of standards where it appears.

Unmet Required Organizational Practice Standards Set


· Medicine Services 7.6· Critical Care 7.7· Ambulatory Systemic Cancer TherapyServices 9.15· Obstetrics Services 9.6

Medication reconciliation at care transitionsWith the involvement of the client, family, or caregiver (asappropriate), the team generates a Best PossibleMedication History (BPMH) and uses it to reconcile clientmedications at transitions of care.

Detailed Required Organizational Practices Results 17Accreditation Report

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Detailed On-site Survey ResultsSection 3

This section provides the detailed results of the on-site survey. When reviewing these results, it is important toreview the service excellence and the system-wide results together, as they are complementary. Results arepresented in two ways: first by priority process and then by standards sets.

Accreditation Canada defines priority processes as critical areas and systems that have a significant impact on thequality and safety of care and services. Priority processes provide a different perspective from that offered bythe standards, organizing the results into themes that cut across departments, services, and teams.

For instance, the patient flow priority process includes criteria from a number of sets of standards that addressvarious aspects of patient flow, from preventing infections to providing timely diagnostic or surgical services. Thisprovides a comprehensive picture of how patients move through the organization and how services are deliveredto them, regardless of the department they are in or the specific services they receive.

During the on-site survey, surveyors rate compliance with the criteria, provide a rationale for their rating, andcomment on each priority process.

Priority process comments are shown in this report. The rationale for unmet criteria can be found in theorganization's online Quality Performance Roadmap.

See Appendix B for a list of priority processes.

ROP Required Organizational Practice

High priority criterion

INTERPRETING THE TABLES IN THIS SECTION: The tables show all unmet criteria from each set ofstandards, identify high priority criteria (which include ROPs), and list surveyor comments related toeach priority process.

High priority criteria and ROP tests for compliance are identified by the following symbols:

Major ROP Test for Compliance

Minor ROP Test for Compliance

MAJOR

MINOR

Detailed On-site Survey Results 18Accreditation Report

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3.1 Priority Process Results for System-wide Standards

The results in this section are presented first by priority process and then by standards set.

Some priority processes in this section also apply to the service excellence standards. Results of unmet criteriathat also relate to services should be shared with the relevant team.

3.1.1 Priority Process: Governance

Meeting the demands for excellence in governance practice.

Unmet Criteria High PriorityCriteria

Standards Set: Governance

The governing body has a succession plan for the CEO.7.8

Surveyor comments on the priority process(es)

There have been significant changes and improvements for the Niagara Health System (NHS) since its previousaccreditation. One major change is the establishment of a new board, with broad administrative andleadership skills. Consistent with the Management Services Agreement in place with St. Joseph’s HealthSystem (SJHS), the CEO Succession Plan is a responsibility of the SJHS Board. The SJHS Board has approved apolicy and process for recruiting the CEO position in the event of a planned or unplanned CEO vacancy.

The board approached accreditation as an opportunity to listen and learn and 'move the bar higher'. Theboard has embraced best practices in governance by way of evaluation using the governance function tool,along with self-evaluations and education. Strides have been made in learning about and using the ethicsframework in making decisions thoughtfully and with adequate procedural justice, even if that means boardmeetings may be longer.

The board members are passionate and knowledgeable individuals that are poised to support and direct NHSis a positive way. All board members receive a comprehensive orientation and in addition, receive ongoingand regular updates like “finance 101” repeatedly as needed. By way of board retreats and meetings they areable to set the tone in order to focus on the patient/client, and the vision and values of the organization.Board meetings are open to the public to increase transparency and openness.

The board oversaw the recruitment and selection process of the new president which began in September2014. According to the board there is 'nothing but praise' for the new president. The board is encouraged toalways have a talent management and succession plan in place. The board has also been successful inmanaging the budget to ensure NHS’ fiscal position is favourable. The board is using a savings priorityframework and identifying opportunities to improve patient care, and improve their reputation and build forthe future.

information to the board in visual ways to help “people-ize” the data. For example, percentages and numbersare used so that board members know the impact in context. The board and community partners indicatethat the level of trust is 'soaring' with these strong partnerships.

Work is underway to transform quality via clinical programs in order to account for quality at the point ofcare and ensure a culture where quality is everybody’s business. The intent is to improve health outcomes,and improve patient satisfaction and sustainability. The areas of quality focus include: efficient care,effective care, safe care, the experience (patient, staff, physicians) and financial health. The board membershave demonstrated that they are committed to quality improvement and “mean what they say.”

The board is encouraged to ensure that the new draft enterprise risk management efforts are supported andthat contingency planning is enhanced.


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information to the board in visual ways to help “people-ize” the data. For example, percentages and numbersare used so that board members know the impact in context. The board and community partners indicatethat the level of trust is 'soaring' with these strong partnerships.

Work is underway to transform quality via clinical programs in order to account for quality at the point ofcare and ensure a culture where quality is everybody’s business. The intent is to improve health outcomes,and improve patient satisfaction and sustainability. The areas of quality focus include: efficient care,effective care, safe care, the experience (patient, staff, physicians) and financial health. The board membershave demonstrated that they are committed to quality improvement and “mean what they say.”

The board is encouraged to ensure that the new draft enterprise risk management efforts are supported andthat contingency planning is enhanced.


The board is focused on the patient, safety and quality improvement. Decision support provides detailed

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3.1.2 Priority Process: Planning and Service Design

Developing and implementing infrastructure, programs, and services to meet the needs of the populations andcommunities served

The organization has met all criteria for this priority process.


The Niagara Health System is a large and diverse community spanning 12 municipalities. There is a strongvolunteer sector that augments the workforce of more than 5000 including physicians and staff.

In 2011/12 a supervisor was appointed and established the strategic plan which focused on quality and safety,access and flow and vision and engagement. Since that time, the NHS has engaged in public polling tounderstand which factors were important to incorporate into strategic planning and to determine corporatepriorities. The results have improved significantly since 2011, demonstrating that nearly 50% of thecommunity now has a positive view of NHS. There is a general sense that people are getting on board withthe plan.

The NHS has conducted clinical services planning to ensure the needs of the region will be met into thefuture. Two large vision days, five patient-centred working groups, and a two-day future state summit wereheld. A project steering committee is overseeing this work.

Decision support plays a key role in providing data to support planning. The needs of the community as wellas priorities set by government are taken into consideration in planning. A good example of this is the closureof in-patient beds at the Niagara on the Lake site, and ensuring that the need for convalescent care in thecommunity was met.

Progress is reported via the Leaders Digest, which is written by the President of NHS. The public can seeinformation regarding wait times/access to emergency and urgent care with new clocks on the external websites, and noted estimated wait times.

The NHS leadership is sensitive to the amount of change that the organization and staff have undergone. Theorganization is utilizing the Kotter model for managing change and is thoughtful about capacity for changegoing forward.


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3.1.3 Priority Process: Resource Management

Monitoring, administration, and integration of activities involved with the appropriate allocation and use ofresources.



The Niagara Health System (NHS) is in a favourable financial position as a result of efforts from all levels ofthe organization. The finance group provides guidelines for budget opportunity savings to address costpressures anticipated for the next few years. A prioritization framework is used to prepare for the HospitalAnnual Planning Submission (HAPS). A decision-making tree is used to ensure fit with the strategies of theLocal Health Integrated Network (LHIN), the province and NHS before proceeding.

Efforts are made to standardize and consolidate to the extent possible to improve quality and patientoutcomes while reducing costs. Samples of operational improvement initiatives (OII) were shared such as:overall impact assessment, impact on staffing, operating savings summary and proposed performanceindicators. Meditech training regarding the finance module is provided by the NHS accounting department. Aswell, business analysts support managers and leaders.

The organization has used an ethicist consultant to help with decision-making around tough choices. Processflows and time lines are in place for capital and operating budgets. As well, there is a process for unbudgetedrequests to address needs as they arise.

Managers can access financial information electronically and are expected to report on variances. Sick andovertime hours are carefully monitored and reported. A physician impact analysis is conducted if a new orreplacement position is required.

Recently, NHS hosted an executive forum entitled: “Spotlight on Innovation…an emerging framework”, whichwas well-attended and described opportunities and examples of innovations of technology, projects and costsavings.


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3.1.4 Priority Process: Human Capital

Developing the human resource capacity to deliver safe, high quality services


Standards Set: Leadership

The organization's leaders establish a talent management plan that includesstrategies for developing leadership capacity and capabilities within theorganization.

10.4

The organization's leaders regularly evaluate reporting relationships andleaders' span of control.

10.9


Occupational health and safety and wellness have been a focus for the Niagara Health System (NHS). Duringthe survey the organization proudly described the Swift Ultraslides, which have already produced a 17%reduction in injuries in the Extended Care unit. As well, the occupational health and safety team hasdeveloped a reference tool to help support staff members in their return to work post injury. There isinterest in finding ways to expand this tool nationally to share these innovative solutions. Staff members arepleased with their three new massage chairs, which are available and regularly used at the St. Catharines,Greater Niagara General Site and Welland Hospital site.

In order to help support open dialogue, the NHS has provided two courses namely: crucial conversations andcrucial accountability, to help support staff members, managers and physician chiefs to promote effectiveworkplace interactions and help improve patient safety.

The results of the NHS employee engagement survey conducted in 2014 indicate an improvement since theprevious survey conducted in 2011. The NHS leaders met with their staffs' and developed action plans toimproved communication and relationship building, as well as retention of staff. A program called: “Walk aMile in My Shoes” has helped staff members to better understand other roles in the health system. Plus, union– management relations are reported to have improved, with decreased grievances. Labour relations workedwith staff members affected by bed closures at the Niagara on the Lake Hospital site in order to successfullytransition them to other positions, or into retirement.

Draft work has commenced regarding establishing a talent management plan to assess staffs' interest andcapacity for moving into leadership positions. Some units have experienced significant management changesin the past few years, and it will be important to establish succession plans and stability going forward. Spanof control is not regularly reviewed, with variability noted in the workload for managers.

An improvement is having a dedicated position focused on workplace relations. Tools and coaching are madeavailable to staff. The Gentle Persuasive Approach (GPA) is available for helping manage patients withdementia. Other tools for staff, such as creative videos regarding workplace violence prevention (using Legocharacters) and another video using a zombie theme, help capture the interest of staff members to watchand learn in an innovative way.

“TLC” has focused volunteers that create a welcoming entrance to the St. Catharines site. In a survey, 98% ofNHS staff members and volunteers indicated that TLC helps improve patient satisfaction by providingattention to the little things that make such a big difference.


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Volunteers play a very important role for NHS and their contributions are notable. One program, namely the“TLC” has focused volunteers that create a welcoming entrance to the St. Catharines site. In a survey, 98% ofNHS staff members and volunteers indicated that TLC helps improve patient satisfaction by providingattention to the little things that make such a big difference.

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3.1.5 Priority Process: Integrated Quality Management

Using a proactive, systematic, and ongoing process to manage and integrate quality and achieve organizationalgoals and objectives



As part of the integrated risk management approach, the organization'sleaders develop contingency plans.

12.3

The organization's leaders disseminate the risk management approach andcontingency plans throughout the organization.

12.4


The Niagara Health System (NHS) has invested in its culture of quality and safety and holds this as a strategicpriority. There is a quality and safety plan and new key personnel are involved in supporting quality andsafety at NHS. One key person is the Chief Safety Officer that partners to ensure actions are put in place toaddress needs. In order to embed quality across the organization, operational directors are assigned therequired organizational practices (ROPs) as one of their accountabilities. The organization used anaccreditation preparation journey approach using: “Route NHS”, which is a curving road map with stops foreach required organizational practice (ROP). The intent was to bring some fun to the accreditation process,using a little bit of competition among units and incentive draws for individuals that participated. Staffmembers report this approach as both helpful and innovative.

The electronic incident reporting system (IRS) provides real-time information to leadership. Level 5 and 6reports are electronically e-mailed to the senior team and a thorough and fulsome process follows forinvestigation and resulting actions. Throughout the NHS, and throughout the survey, staff members andphysicians were able to articulate the disclosure policy and process. There is always a senior leader andquality/safety staff on call.

Medication reconciliation has been supported with dedicated financial support of $1 million, and has beenimplemented in pediatrics and mental health. There is new medical leadership supporting medicationreconciliation, as well as nurse practitioners, and the tone is positive when this was discussed with staff andphysicians. The organization has a plan to roll out medication reconciliation fully in the next three years.

The Inter-professional Education for Quality Improvement Program (I-Equip) is a partnership between NHS,Brock University and McMaster University. The program provides students from various disciplines with theoryand practical application of quality improvement, leadership, and project management. The goal is to helpthe NHS complete valuable projects in quality improvement, while inspiring future generations of healthproviders and leaders. This program has been in place for a few years and has been over-subscribed to thepoint that interviews and a selection process now occurs for student admission.

to provide more patient-centred care. The huddle boards, including the NHS priorities and unit/departmentalgoals and indicator details are regularly used in all service areas, and provide transparency for staff membersand patients to contribute to improved quality of care. Rhythm rounds are able to help keep the momentumof initiatives at all levels of the organization.

The organization does not currently have an integrated approach to contingency planning. Documentationreviewed during the on-site survey indicates that NHS sees this as a significant risk and there are plans tocontract external support using a Request for Proposal (RFP). The risk management approach is very new andthe organization has not yet had an opportunity to roll it out. The approach taken to develop the draftintegrated/enterprise risk plan was robust, including literature and best practice review and the organizationis encouraged to finalize this important work. There is a RFP in progress to seek support for contingencyplanning for NHS.


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Across the NHS, the implementation of patient white boards has been instrumental in improvingcommunication between patients, family and care givers. These boards include critical patient safetyconsiderations, such as handwashing, patient identification and so on as well as other important informationto provide more patient-centred care. The huddle boards, including the NHS priorities and unit/departmentalgoals and indicator details are regularly used in all service areas, and provide transparency for staff membersand patients to contribute to improved quality of care. Rhythm rounds are able to help keep the momentumof initiatives at all levels of the organization.

The organization does not currently have an integrated approach to contingency planning. Documentationreviewed during the on-site survey indicates that NHS sees this as a significant risk and there are plans tocontract external support using a Request for Proposal (RFP). The risk management approach is very new andthe organization has not yet had an opportunity to roll it out. The approach taken to develop the draftintegrated/enterprise risk plan was robust, including literature and best practice review and the organizationis encouraged to finalize this important work. There is a RFP in progress to seek support for contingencyplanning for NHS.

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3.1.6 Priority Process: Principle-based Care and Decision Making

Identifying and decision making regarding ethical dilemmas and problems.



The organization is particularly proud of the collaborative work of a group of professionals, work originatingfrom multiple sites and group members working closely, with an expert consultant ethicist producing aninnovative ethics framework that readily received full support across all programs and all sites. Introducingthe situation-background-assessment-recommendation (SBAR) element, already used in other areas of care,crystallized the process that guides the discussions when addressing complex ethics issues be they end-of-lifeissues, allocation issues or corporate level decisions.

In addition to the unit-level internal discussions that take place when addressing care issues, the importantelement of this framework is the question regarding the decision to inform the public/community of anydifficult decisions or situations facing the organization. This is an important component with which manyorganizations struggle, and having this element as part of the framework takes out all the guess work and thelong deliberations whether one should come out publicly or not. It guides the discussions.

The positive outcome since the introduction of the framework, as per the users, is that it now provides teammembers with a voice.

The organization has a full research ethics committee fulfilling its two-fold mandate of protection ofparticipants in research studies and facilitating research.


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3.1.7 Priority Process: Communication

Communicating effectively at all levels of the organization and with external stakeholders



The organization has a communications department which is robust and has responsibility for all internal andexternal communications. This department has played a pivotal role in enhancing positive communication forthe organization.

The communication strategy involves communication tools for external contacts using twitter, Facebook,print, television and radio. There are weekly e-blasts and intranet messaging for internal stakeholders. All ofthese communication techniques are regularly monitored and modifications are made if required. This hasresulted in a growing sense, both internally and externally that the organization is transparent andcommunicative.

External publications such as: Niagara Health Now, Niagara Health System Annual Report and local newspaperarticles depict the patient story around care. Internal communications such as: The President's Newsletter,Leaders Digest and The Pulse focus on important staff messages. There is strong evidence at the bedside thataccreditation messages were received and understood as they prepared for this survey visit.

Safety posters and the My Space patient board have enhanced communication with clients/patients receivingservice from the Niagara Health System. The 'Online Community' resource for dialysis patients is an innovativeapproach to enhance communication and promote self-management between this patient group.

The organization has developed excellent communication channels at all levels namely: staff members,community and health care partners; and the Local Health Integrated Network and local government. Thesechannels will be instrumental as the organization moves forward with the strategic plan and its brandrenewal process.


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3.1.8 Priority Process: Physical Environment

Providing appropriate and safe structures and facilities to achieve the organization's mission, vision, and goals



The Niagara Health System (NHS) comprises a modern facility and several others that date back many years.The organization has made significant investment in repairing and advancing service systems in many of theolder facilities. Given this context and that there are plans, already underway, to bring the entireorganization into two facilities in the future, the direction taken to ensure that all situations compromisingsafety are addressed is working for the organization.

Power, water and heating back-up systems have undergone recent maintenance and upgrades and areregularly tested to ensure that they function appropriately. The organization has ensured that maintenanceof the buildings continues and appropriate renovations have been made to ensure capacity in the sitefacilities. However in some areas, due to the age of the buildings, some damage to plastered walls wasobserved during the on-site tours. Repairs to such will facilitate cleaning of those surfaces.

There is close collaboration and coordination of efforts across multiple services as well as with the jointhealth and safety committee for some projects to ensure the success of projects. Examples of this are thedepartment/unit inspection visits that address safety issues, and the Connexall project spanning, nursing,porters, environmental services and admitting for improving patient flow to the assigned bed. The team isparticularly proud of its Environmental Awareness program impacting on the greenhouse effect anddecreasing the carbon foot print. The team works closely with community partners such as the environmentalprogram at Niagara Sustainability Initiative.

The team is most proud of its standardization of cleaning methods which now includes a scientificcomponent.

Given that some services originally housed on other sites have now moved out of the facilities to the maincomplex in St. Catharines there is the potential for some of the offices/spaces to be occupied temporarily bystaff members, but not necessarily known to management. The organization is encouraged to maintain itsspace allocation/occupancy list and regularly update it so as to address any potential safety issue shouldthere be a need to evacuate the building.

Significant progress has been made to standardize signage across the facilities.


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3.1.9 Priority Process: Emergency Preparedness

Planning for and managing emergencies, disasters, or other aspects of public safety



The organization's leaders develop and implement a business continuityplan to continue critical operations during and following a disaster oremergency.

14.9

The business continuity plan addresses back-up systems for essentialutilities and systems during and following emergency situations.

14.10


The organization has committed to the development of a comprehensive emergency preparedness approach.Significant effort has resulted in the development of an initial all-hazards plan, a reputation crisiscommunication plan, pandemic plan, Ebola planning, and the change to the incident command system (ICS).Plans are currently not integrated and the organization has already identified this as a risk. This has resultedin the plan to contract external support to create a fully integrated all-hazards plan including businesscontinuity. The organization is commended on the planning of the St. Catharines site. The facility has beendesigned with internal redundancy in a number of areas that will enable it to respond to a variety of internaland external system failures or emergency events.

The organization has committed resources for training with a focus on staff understanding of codes, and theevent-specific plans that are in place. The organization provided focused education for staff members andleaders to prepare them for the Pan American Games that were held locally in the summer of 2015. Theorganization is planning to issue a request for proposal (RFP) for a more robust learning management system.This initiative will be valuable for the organization to evaluate effectiveness of training as well as foraccountability that training has occurred.

The organization is exercising plans on a regular basis to ensure it is prepared to respond to events shouldthey occur. The Niagara Health System (NHS) has demonstrated a commitment to improving plans, educatingstaff, and implementing preventative initiatives. Some examples of these efforts include emergencypreparedness and infection prevention and control as regular topics in huddle conversations and at jointoccupational health and safety committee meetings. The organization also collaborated with the Ministry ofLabour to ensure the code orange plans meet staff safety standards, and the NHA is seen as a champion withthis work. The organization participates in local planning committees, and is working toward alignment ofplans with its partners. This is clearly evident in the move to the Incident Command System (ICS). Staffmembers reported during the survey visit that they are establishing collaborative approaches and areparticipating with local emergency operations centre's table-top exercises.

The organization is in the process of developing a business continuity plan. There are aspects of the plan inplace, particularly at the St. Catharines'site for specific event types. Documentation reviewed during theon-site survey indicates that NHS sees this as a significant risk and there are plans to contract externalsupport via a Request for Proposal (RFP).

The NHS has established back-up utility suppliers for the St. Catharines site to ensure a secondary supply in acase of prolonged loss of utilities. The organization does not appear to have the same arrangement in placefor the remaining facilities across the organization. The organization is encouraged to expand its contractswith suppliers to include all facilities. Detailed On-site Survey Results 30Accreditation Report

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The NHS has established back-up utility suppliers for the St. Catharines site to ensure a secondary supply in acase of prolonged loss of utilities. The organization does not appear to have the same arrangement in placefor the remaining facilities across the organization. The organization is encouraged to expand its contractswith suppliers to include all facilities.


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3.1.10 Priority Process: Patient Flow

Assessing the smooth and timely movement of clients and families through service settings



The Niagara Health System has identified access and flow as an organizational client safety strategic priority.A variety of strategies have been implemented to address access and flow issues. These include department,site, and organizational level initiatives. Daily unit huddles facilitate communication among interdisciplinaryteam members enabling collaboration and decision making, and provide clarity on important areas of focusfor the team. These unit huddles also review unit performance and recognize team success. Weekly roundsfocused on reviewing performance metrics called Rhythm Rounds are helping keep momentum of initiatives.Managers are free from all meetings prior to 10 am to allow a presence on the unit to meet team members,patients and families, and to perform "standard work", which is a collection of indicator data that is used tomeasure goal and objective performance. This information is submitted to Directors and ExecutiveVice-President for review.

Services are available on a 24 hour basis out of three Emergency departments and two urgent care centres.There is a system wide approach to service delivery with mechanisms to move clients to the site that is bestequipped to safely meet their care needs.Teams are well versed in the available supports to transport clients for care; this includes home hospitalrepatriation, and transfer to a higher level of care. The NHS utilizes the services provided by Criticall Ontarioto assist with arranging urgent transport and bed finding.

Processes have been developed to guide teams in the preparation and transfer of clients. These processeswere observed during the survey visit and were effectively followed. Feedback by receiving departmentsreport information is accurate however, at times patients can be on their way before all notifications haveoccurred.

Surge plans are in place across the NHS. These plans include a number of strategies from identified beds forover capacity, and available patient care units that could be made operational if circumstances required.There are twice-daily patient flow rounds at a site level, and alternate level care (ALC) rounds withcommunity partners, and organization-wide patient flow calls. During the survey visit the collaborativeapproach was clearly evident at patient flow rounds.

There is a true systems approach for dealing with the complex issues that impact access and flow. Theorganization recently implemented a computer-based system that provides real-time information for bothclients and team members on the current wait time in the emergency departments (EDs) and urgent carecentres.

The NHS recently implemented a number of technology tools to assist teams with access and flow strategies.These systems provide up to date information on a number of data elements such as occupancy, patientswaiting for beds, quality measures such as Emergency department admissions needing beds, surgical casesneeding beds, and potential discharges. This system has provided transparency for teams to see the entirepicture and to allow them to participate in improving the situation.

that demonstrate innovation and collaboration include the regional approach to winter pressures. The NHSorganized a planning session with partners from across sectors and the Local Health Integrated Network(LHIN) and developed five strategies: a nurse practitioner (NP) mobile rapid response team; an equipmentrepository; winter resilience command centre; advanced communication for residents returning to long-termcare, and public health communication related to outbreaks. These five strategies, along with initiatives havea goal of preventing avoidable admissions, common approaches to patient flow, discharge planning, andinfection prevention to allow safe transfers during outbreaks.

The NHS has made a significant impact on barriers to access and flow such as: reduction in lengths of stay insurgery; complex care; cardiology, respirology and mental health; attention to emergency departmentlengths of stay; avoiding night time transfers and addressing delays to discharge associated withorganizational process or service. The NHS has been able to reduce the number of alternate level care (ALC)patients waiting in hospital, and has cancelled less than five cases related to bed pressures in the past year;and it has decreased lengths of stay in many programs.


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The NHS has made collaboration with partners a priority strategy in meeting goals and objectives. Examplesthat demonstrate innovation and collaboration include the regional approach to winter pressures. The NHSorganized a planning session with partners from across sectors and the Local Health Integrated Network(LHIN) and developed five strategies: a nurse practitioner (NP) mobile rapid response team; an equipmentrepository; winter resilience command centre; advanced communication for residents returning to long-termcare, and public health communication related to outbreaks. These five strategies, along with initiatives havea goal of preventing avoidable admissions, common approaches to patient flow, discharge planning, andinfection prevention to allow safe transfers during outbreaks.

The NHS has made a significant impact on barriers to access and flow such as: reduction in lengths of stay insurgery; complex care; cardiology, respirology and mental health; attention to emergency departmentlengths of stay; avoiding night time transfers and addressing delays to discharge associated withorganizational process or service. The NHS has been able to reduce the number of alternate level care (ALC)patients waiting in hospital, and has cancelled less than five cases related to bed pressures in the past year;and it has decreased lengths of stay in many programs.

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3.1.11 Priority Process: Medical Devices and Equipment

Obtaining and maintaining machinery and technologies used to diagnose and treat health problems



A new reprocessing department has opened at the St Catharines site. As a result of this, the previousdeficiencies identified have been addressed. Staff members had significant input to the new departmentparticularly as to how it would look and how it would function. At the Niagara Falls site, all deficienciesidentified in the previous accreditation survey report have been addressed by extensive renovations andimprovement in movement of supplies and equipment. This was accomplished with input from infectionprevention and control (IPAC). At the Welland site, many of the required renovations have been completed.Finishing touches will be done during the operating room (OR) closure. The major work required is theaddition of pass-through doors to allow better flow of equipment between areas.

Both bio-medical and central supply reprocessing (CSR) have huddle boards. Quality initiatives have beendeveloped specific to each department. These are aligned with the strategic plan. The bio-medicaldepartment recently underwent a successful peer review by its professional organization, The CanadianMedical and Biological Engineering Society (CMBES).

The CSR staff members must be college graduates to be employed. The majority of staff members and themanager have certification for medical devices reprocessing (MDR). Those not yet certified are currently inthe process of obtaining certification. Yearly competency training is in place and mandatory for all staff.Updates occur as required. Performance evaluations occur on a yearly basis. There is now a single corporatemanager in place, with site manager presence at sites where reprocessing is done.

All the policies and procedures related to reprocessing are available online and have been standardizedacross the organization. All the equipment sterilized is identified and able to be tracked should breaks insterility be identified.

Environmental services and infection prevention and control (IPAC) are actively involved in maintaining aclean and safe environment for reprocessing. The frequency of areas to be cleaned is in line with thepublished standards. There are no external contracts in place for sterilization. All reprocessing is done inhouse. A policy and procedure for handling loaner equipment is in place, and familiar to all appropriate staff.

The St. Catharines' area is spacious and not cluttered. The Niagara Falls site area has some space constraints.Access to all areas in MDR is restricted. Ultrasound probe reprocessing is performed in all the NHS diagnosticimagine (DI) units. Reprocessing and cleaning is done in locations that have been deemed to be safe withinput from IPAC and MDR staff. Policies and procedures have been developed providing detailed instructionsrelated to reprocessing probes. The Trophon processor is utilized in all areas.

Sterilization of endoscopes occurs in the endoscopy unit. All scopes are processed according tomanufacturers' instructions and established policies and procedures. All scopes are identified and tracked sothat if any outbreaks occur they can be tracked to a specific patient.

a central department in Welland. A technician with appropriate skills and knowledge is then assigned. Thereis commitment to have all critical devices back in service within 24 hours. Technicians must have a biomedical technology course before they are hired. Most of the repairs are done in house. Technicians receiveongoing training and updates related to equipment in use.

All sites have in place a preventive maintenance schedule. All equipment has specific identification markersthat allow technicians to narrow down their locations. This also allows them to identify the specific deviceand perform the required maintenance. If the bio-medical department is unable to carry out the repairs themanufacturers' service department is contacted.

The only departments that have external contracts are the laboratory and digital imaging departments.

Noted strengths are staff training and education, strong commitment to safety and quality and strongcorporate leadership in both departments. Another key strength is the recent update in policies andprocedures by bio-medical and the willingness to share a mobile application tool developed to aid in diagnosisand repairs of medical devices.


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The bio-medical department now has an organization leader in charge of all sites. All the sites have on sitehuman resources to manage the workload. Requests for repairs are generated by the nursing staff and sent toa central department in Welland. A technician with appropriate skills and knowledge is then assigned. Thereis commitment to have all critical devices back in service within 24 hours. Technicians must have a biomedical technology course before they are hired. Most of the repairs are done in house. Technicians receiveongoing training and updates related to equipment in use.

All sites have in place a preventive maintenance schedule. All equipment has specific identification markersthat allow technicians to narrow down their locations. This also allows them to identify the specific deviceand perform the required maintenance. If the bio-medical department is unable to carry out the repairs themanufacturers' service department is contacted.

The only departments that have external contracts are the laboratory and digital imaging departments.

Noted strengths are staff training and education, strong commitment to safety and quality and strongcorporate leadership in both departments. Another key strength is the recent update in policies andprocedures by bio-medical and the willingness to share a mobile application tool developed to aid in diagnosisand repairs of medical devices.

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3.2 Service Excellence Standards Results

The results in this section are grouped first by standards set and then by priority process.

Priority processes specific to service excellence standards are:

Episode of Care - Ambulatory Systemic Cancer Therapy

Healthcare services provided for a health problem from the first encounter with a health care providerthrough the completion of the last encounter related to that problem.

Point-of-care Testing Services

Using non-laboratory tests delivered at the point of care to determine the presence of health problems

Clinical Leadership

Providing leadership and overall goals and direction to the team of people providing services.

Competency

Developing a skilled, knowledgeable, interdisciplinary team that can manage and deliver effective programsand services

Episode of Care

Providing clients with coordinated services from their first encounter with a health care provider throughtheir last contact related to their health issue

Decision Support

Using information, research, data, and technology to support management and clinical decision making

Impact on Outcomes

Identifying and monitoring process and outcome measures to evaluate and improve service quality and clientoutcomes

Medication Management

Using interdisciplinary teams to manage the provision of medication to clients

Organ and Tissue Donation

Providing organ donation services for deceased donors and their families, including identifying potentialdonors, approaching families, and recovering organs

Infection Prevention and Control

Implementing measures to prevent and reduce the acquisition and transmission of infection among staff,service providers, clients, and families

Surgical Procedures

Delivering safe surgical care, including preoperative preparation, operating room procedures, postoperativerecovery, and discharge


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Diagnostic Services: Imaging

Ensuring the availability of diagnostic imaging services to assist medical professionals in diagnosing andmonitoring health conditions

Diagnostic Services: Laboratory

Ensuring the availability of laboratory services to assist medical professionals in diagnosing and monitoringhealth conditions

Transfusion Services

Transfusion Services

3.2.1 Standards Set: Ambulatory Systemic Cancer Therapy Services - DirectService Provision


Priority Process: Episode of Care - Ambulatory Systemic Cancer Therapy

With the involvement of the client, family, or caregiver (as appropriate),the team generates a Best Possible Medication History (BPMH) and uses it toreconcile client medications at ambulatory care visits where the client is atrisk of potential adverse drug events*. Organizational policy determineswhich type of ambulatory care visits require medication reconciliation, andthe how often medication reconciliation is repeated.

*Ambulatory care clients are at risk of potential adverse drug events whentheir care is highly dependent on medication management OR themedications typically used are known to be associated with potentialadverse drug events (based on available literature and internal data).

9.15 ROP

9.15.1 The organization identifies and documents the type ofambulatory care visits where medication reconciliation isrequired.

MAJOR

9.15.2 For ambulatory care visits where medication reconciliation isrequired, the organization identifies and documents howfrequently medication reconciliation should occur.

MAJOR

9.15.4 During or prior to subsequent ambulatory care visits, the teamcompares the Best Possible Medication History (BPMH) with thecurrent medication list and identifies and documents anymedication discrepancies. This is done as per the frequencydocumented by the organization.

MAJOR

9.15.5 The team works with the client to resolve medicationdiscrepancies OR communicates medication discrepancies tothe client's most responsible prescriber and documents actionstaken to resolve medication discrepancies.

MAJOR

9.15.6 When medication discrepancies are resolved, the teamupdates the current medication list and retains it in the clientrecord.

MAJOR


QMENTUM PROGRAM

Priority Process: Clinical Leadership


Priority Process: Competency


Priority Process: Decision Support


Priority Process: Impact on Outcomes


Priority Process: Medication Management



Priority Process: Episode of Care - Ambulatory Systemic Cancer Therapy

Clients feel well cared for and respected by all staff. They feel that staff members are vigilant, qualified andtruly caring of them and for their families. They feel fortunate that their questions are responded to asquickly as possible, and that they always have a person to contact should something arise outside of clinichours.

Staff members adhere to the high-alert policy and help one another by being freely available to each other toperform an independent double check.

All patients entering the clinic have a best possible medication history (BPMH) documented during the firstvisit. This history of medications is updated whenever staff members learn of any new or changedmedications. The act of reconciliation was not observed in this clinic during the survey visit. The team isencouraged to explore ways that they can incorporate reconciliation into their practice, as appropriate.


The St. Catharines site has a state-of-the-art facility to provide ambulatory oncology services, and the staffmembers contributed to the layout and design. Continuous quality improvement occurs using a combinationof data and input/feedback from patients, families and staff.

The staff members recognize the need to closely align with the needs of their patients and the communitiesthey serve. The team sought a patient and family advisor to guide them in the design of their service deliverymodel.


QMENTUM PROGRAM


One of the unique design features at the St Catharines site is the workspace/office pod. This pod designfacilitates an effective, comprehensive and cohesive team environment.

This unique team model includes a "DAF" pharmacy technician that supports the patient/family and team byensuring that the patient does not encounter barriers in obtaining medications in the community. The modelensures that appropriate paperwork is completed and payment submissions receive appropriate approval.


The MOSAIQ software system provides a unique level of insight for staff members that work in the ambulatorysetting in that they are able to confirm patient status as the patients flow through the myriad of assessmentsand treatment procedures. At any point, staff members are able to view this information along with keyclinical information found in the electronic chart. This software is also visible to those that have NiagaraHealth System Meditech access privileges.


Staff members are engaged in the active utilization of the quality and safety board which facilitates real-timediscussion of potential risks/concerns. The quality and safety board is designed in a manner that ensures thatmeasurable objectives are identified and tracked. The board is entirely visual and transparent. It utilizes aheat-map chart format that simplifies the prioritization of recommendations and ensures that they arehandled to completion.

The Niagara Health System incident reporting system (IRS) is a quick, accessible mechanism that encouragesstaff members to submit reports of events. The data are regularly extracted from the IRS and reviewed toidentify opportunities for improvement. The team displays a strong commitment to ongoing qualityimprovement, with documentation of the changes that they have made in response to reported events.


There is use of prescriber ordering using provincial oncology program pre-printed orders to ensure approvedcomprehensive protocols. In the interdisciplinary format, the orders are reviewed by a pharmacist beforethey are provided to the satellite pharmacy for preparation.

The clinic has a dedicated oncology satellite pharmacy that meets the pharmacy professional guidelines. Thestaff members are experienced and knowledgeable in the area of chemotherapy preparation. The ambulatoryclinic staff members are pleased with the rapid response of pharmacy staff members to prepare neededintravenous solutions in a timely manner. Chemotherapy infusion lines are primed with hydration solutions toremove this potential exposure risk for nurses. Although solutions are prepared just prior to administration,the primed lines are run in advance. The primed lines are then stored at room temperature until needed. Theorganization may wish to explore the literature regarding whether such items require refrigeration or storageat room temperature.


QMENTUM PROGRAM

3.2.2 Standards Set: Biomedical Laboratory Services - Direct ServiceProvision


Priority Process: Diagnostic Services: Laboratory



Priority Process: Diagnostic Services: Laboratory

Many of the standards in diagnostic laboratory services were previously reviewed for compliance by theOntario Laboratory Association (OLA). The team is commended for the Inter-professional Practice TeamAwards that are delivered to some of the staff members for their involvement in particular projects. Some ofthese staff members are also members of organizational committees such as the transfusion committee andtheir participation in such has led to the development of the: "Lab Test Information Guide" which has had asignificant impact on the quality and accuracy of the specimens received from the clinical units. Participationof staff members in committees has resulted in changes to some of the order sets with a result in changes tothe laboratory test profile for some diagnoses.

The team is encouraged to continue with its daily huddle boards and monitoring of its quality metrics withthe goal of informing staff members on how well they are doing and what needs to be improved.

Stringent control as to the compliance of laboratory users with the established procedures for requisitionlaboratory tests is done by a laboratory nurse that reviews all occurrences of non-compliance. The team isstrongly encouraged to continue with this practice.


QMENTUM PROGRAM

3.2.3 Standards Set: Cancer Care and Oncology Services - Direct ServiceProvision






Priority Process: Episode of Care

The team has a process to evaluate client requests to bring in orself-administer their own medication.

10.6







The program works closely with its partners both in the site and external to the site. While this has resultedin the demand for services exceeding program capacity, the team has revisited its model in order toaccommodate patients awaiting their care.


Staff members' educational needs are fulfilled however, on occasion there is a need for more experiencedmembers of the team to mentor the more junior team members. Staff members have access to nursepractitioners and pain control experts to assist them when needed.


The organization has a true medication reconciliation champion, as evidenced by the chart review during theon-site survey. Of note is that the physician had completed a medication reconciliation discharge plandocument that was perfectly and comprehensively completed.


QMENTUM PROGRAM


Staff members have access to sufficient work stations including a mobile unit. By way of these work stations,staff members on the unit use the Meditech software platform however, they also have access to additionaltreatment information which is found in the oncology chart and stored in MOSAIQ software system.


The staff members utilize a number of tools to advance their quality initiatives. Tools included: thewhiteboard on the unit that specifies patient precautions/risks; fall risk posters; quality and safety board andthe organizational priorities and goals board. These tools are actively used to document and engage staffmembers in the quality improvement journey.


QMENTUM PROGRAM

3.2.4 Standards Set: Critical Care - Direct Service Provision







With the involvement of the client, family, or caregiver (as appropriate),the team generates a Best Possible Medication History (BPMH) and uses it toreconcile client medications at transitions of care.

7.7 ROP

7.7.5 The team provides the client, community-based health careprovider, and community pharmacy (as appropriate) with acomplete list of medications the client should be takingfollowing discharge.

MAJOR





Priority Process: Organ and Tissue Donation




The Niagara Health System (NHS) has implemented a number of initiatives such as department huddles,program planning, and unit and site-specific and organization-wide patient flow focus. These initiatives havehad a transformational impact on the organization, as observed during the on-site survey. Staff membersfrom each department are able to identify department, program and organizational goals and objectives.They verbalize seeing themselves as a part of the plan, the solution, and the results. The commitment ofteams at all sites is clearly evident in their client-centred approach to care.

Goals and objectives have been established at all sites. The goals and objectives are aligned withorganization-wide strategy and those required of the Local Health Integration Network (LHIN), as well as theprovincial health ministry. Staff members review their performance at daily huddles, and weekly rhythmrounds. The organization has a growing academic role, with increased numbers of 'learners' and a desire toparticipate in research. Teams are motivated to do original research that will allow them to provide newmethods of caring for their patients in new and more effective ways.

The organization has made significant efforts to create work environments, processes and equipment that isstandardized across all sites. During the on-site survey visits to the sites, staff members verbalized having theequipment needed to do their work; they understood the organization's approach to capital equipmentplanning, and felt their needs were promptly addressed.

The organization has made access and flow a strategic priority. The critical care program has responded witha number of initiatives to be able to provide the services when needed. These include surge capacity acrossthe system. The three units work together and support the other when needed. The organization also workswith adjacent partners such as Hamilton when needed.


QMENTUM PROGRAM

rounds. The organization has a growing academic role, with increased numbers of 'learners' and a desire toparticipate in research. Teams are motivated to do original research that will allow them to provide newmethods of caring for their patients in new and more effective ways.

The organization has made significant efforts to create work environments, processes and equipment that isstandardized across all sites. During the on-site survey visits to the sites, staff members verbalized having theequipment needed to do their work; they understood the organization's approach to capital equipmentplanning, and felt their needs were promptly addressed.

The organization has made access and flow a strategic priority. The critical care program has responded witha number of initiatives to be able to provide the services when needed. These include surge capacity acrossthe system. The three units work together and support the other when needed. The organization also workswith adjacent partners such as Hamilton when needed.


There are strong interdisciplinary teams that are delivering care for critical care at each of the sites, eachensuring the right mix and number to provide care. There is robust and well-developed standardizedorientation and training. A career ladder approach has been developed, allowing critical care units to offerexperienced nurses from other sites and units to work in the intensive care unit. They also offer learningopportunities for brand new nursing graduates and help them expand confidence in their practice over time.Education and training is provided in a variety of ways. There are annual comprehensive skills days,designated educators, access to e-learning and funds for professional development.


The Niagara Health System (NHS) has developed a standardized assessment and policies and procedures forcritical care units across the organization. This includes the identification of individuals at risk of venousthrombo embolism. All patients are screened on admission and identified for prophylaxis. Audits are donedaily to ensure patients have not been missed. At times, there is a gap where audits and documentation donot match.

A critical care response team was recently rolled out at the St. Catharines site and it operates 24 hours perday. There are established criteria in place for when to call the team, as well as roles of team members, andaccountabilities of the team are identified.

The best possible medication history (BPMH) is completed on admission; this can be performed in theemergency department or in critical care within a 24-hour time frame when the client is critical in nature. Itis extremely rare for a client to be discharged directly to the community and therefore, medicationreconciliation on transfer processes are currently not in place. This will be addressed by the organizationwhen it implements medication reconciliation at transfer and discharge in the spring of 2016.

Staff members use a variety of communication tools when patients are not able to communicate verbally.Staff members, patients and their families report that the white boards in the patient rooms are a valuabletool for communicating and ensuring patients have input to their plan of care.

All patients are provided with an orientation booklet at the time of admission. Information is provided forthem and their families on what to expect, how to participate, and how to make the organization aware oftheir expectations if they are not being met.

Processes are in place to guide the team when making decisions regarding cessation of life sustainingtreatment; the organization also provides access to ethical and pastoral care support. Staff members reportthis support has been utilized and is of significant value with some challenging and complex cases.


QMENTUM PROGRAM

Processes are in place to guide the team when making decisions regarding cessation of life sustainingtreatment; the organization also provides access to ethical and pastoral care support. Staff members reportthis support has been utilized and is of significant value with some challenging and complex cases.


Patient records are kept private and confidential. A standardized assessment is used across all sites. Theteam has successfully obtained resources to add new equipment that will allow advances and approaches tocare in new ways.

Standardized order sets and protocols are in use across all intensive care units. Evidence-based protocols forcare have been established. Hamilton Health Science’s expertise is drawn upon. The Niagara Health System isbecoming more involved in clinical academics. Team members have been recognized for their work and havepublished their work. New opportunities for research are planned for the future and there is a great deal ofexcitement as a result.


The Niagara Health System has implemented an incident reporting system for reporting events. Staffmembers also identify situations with their managers and at daily huddles. Issues are reviewed, andresolution identified, implemented and evaluated.

Staff members are fully knowledgeable in how, when and why to enter events into the incident reportingsystem. They state safety issues are discussed at unit huddles and solutions are developed collaboratively.

The organization is measuring a number of indicators including: falls; admission to bed times; readmissionrates; avoidable beds days; hand-hygiene compliance; ventilator associated pneumonia rates; central lineinfection rates; unplanned extubation rates; critical care response team activities; night time discharge ratesand antimicrobial utilization. These topics are discussed at program committee meetings and during rhythmrounds.

All patients are provided with an orientation booklet at the time of admission. Information is provided tothem and their families on what to expect, how to participate, and how to make the organization aware oftheir expectations if they are not being met. Client satisfaction surveys are conducted, as well as directfeedback by clients and their families.


The organization is not responsible for the organ and tissue program. This service is led by an externalpartner. The Niagara Health System has established strong linkages with this partner. Policies are in place,staff members have received education, and potential donors are identified. Missed opportunities are trackedand reviewed.


QMENTUM PROGRAM

3.2.5 Standards Set: Diagnostic Imaging Services - Direct Service Provision


Priority Process: Diagnostic Services: Imaging

For nuclear medicine, the team designates separate waiting areas tosegregate clients who have been injected with radioactive substances fromother clients.

4.3

For interventional procedures, the team labels, handles, transports, tracksand stores samples safely and appropriately.

11.14


Priority Process: Diagnostic Services: Imaging

The diagnostic imaging (DI) team is enthusiastic and has an obvious focus on patient-centred care. Acomprehensive service is provided to meet the needs of the patients in this region. There is clearcommitment to integration and standardization across the system. Centralized booking processes havesignificantly reduced wait times for some modalities including computerized tomography (CT), magneticresonance imaging (MRI), and also have contributed to exceeding provincial targets.

Quality Indicators are monitored and posted on safety huddle boards in the department. The DI staffmembers are commended for their participation in initiatives to improve emergency department (ED) waittimes and ensuring access to important services such as CT 24 hours per day.

Turn around times for all modalities are monitored and reviewed during daily huddles, with notableimprovements. The recent project to improve the no-show rate for scheduled appointments will furtherenhance efficiency in the department. Two client identifiers are completed during the registration processand prior to every examination at all sites. Some significant work has been completed to ensureunderstanding of the importance of this process for out-patients. A unique approach to identifying fall risks inthe out-patient population has resulted in high compliance in risk identification.

The new unit at the St. Catharines site is state of the art and built to ensure privacy, maximize patient flowand create appropriate care areas for both in-patients and out-patients that require services. The team isencouraged to continue the evaluation of services required at all sites as the NHS moves forward, and inrelation to the digital requirements for equipment such as mammography at the Douglas Memorial Hospitalsite.


QMENTUM PROGRAM

3.2.6 Standards Set: Emergency Department - Direct Service Provision
















The organization has implemented a number of initiatives such as department huddles, program planning,and unit, site-specific and organization-wide patient flow focus. These initiatives have had a transformationalimpact on the organization, as observed during the survey. Staff members of each emergency department areable to identify department, program and organizational goals and objectives. They verbalize seeingthemselves as a part of the plan, the solution, and the results. The commitment of teams at all sites isclearly evident in their client-centred approach to care.

Goals and objectives have been established at all sites. The goals and objectives are aligned withorganization-wide strategy and those required of the Local Health Integration Network (LHIN), as well as theprovincial health ministry. Staff members review their performance at daily huddles and weekly rhythmrounds.

The emergency departments (EDs) play a significant role in the development, review and exercise of theorganization's all-hazard plan and more work in the area of contingency planning is encouraged. Leaders fromthe EDs participate on the organization's emergency preparedness committee.

The organization has made significant efforts to create work environments, processes and equipment that isstandardized across all sites, including pediatric equipment. During the on-site survey visits staff members atall sites verbalized having the equipment needed to do their work. They understood the organization'sapproach to capital equipment planning, and felt their needs were promptly addressed.

Access to secure seclusion rooms are available at all three EDs, and both the urgent care centres have privatespaces for the care of individuals that present with mental health or behavioural needs while awaitingtransfer to higher level care.


QMENTUM PROGRAM

The organization has made significant efforts to create work environments, processes and equipment that isstandardized across all sites, including pediatric equipment. During the on-site survey visits staff members atall sites verbalized having the equipment needed to do their work. They understood the organization'sapproach to capital equipment planning, and felt their needs were promptly addressed.

Access to secure seclusion rooms are available at all three EDs, and both the urgent care centres have privatespaces for the care of individuals that present with mental health or behavioural needs while awaitingtransfer to higher level care.


Strong interdisciplinary teams deliver care at all sites, each ensuring the right mix and number to providecare in the respective emergency departments. There is robust and well-developed orientation. This includesa tiered orientation program, ensuring that only experienced emergency department (ED) nurses work in thetriage area.

A career ladder approach has been developed, allowing EDs to accept existing nurses to allow them newopportunities. There is also a strategy focused on brand new nursing graduates and help for them to gainconfidence in their practice over time. Education and training is provided in a variety of ways. There areannual comprehensive skills days, ED educators are available, and there is access to e-learning and funds forprofessional development.


A tremendous effort has been expended in the standardization of processes and procedures across theNiagara Health System (NHS). Patients are able to locate the emergency department (ED) at the ED sites, andinternal signage in the waiting rooms is helpful in way-finding. There is a challenge in the size of the St.Catharines site in that once inside the ED, patients and their families could feel “lost”.

The entrance to the urgent care area at the Port Colborne site has an outside door. This door leads to a smallarea with a second door leading to the corridor of the urgent care area. The inside door to the urgent carearea is closed at 2300 hours. Clients that arrive after 2300 hours and make it through the first door are nowfaced with a locked door. There is a red sign on the wall instructing persons to press the red button to openthe inside door. Normally, there is a security guard there after 2300 hours that will open the door if theperson has not activated the red button to open the door. However, the security guard must make rounds ormay be called to attend to a situation elsewhere in the building thus leaving the station outside the urgentcare area vacant. The Port Colorne facility is highly encouraged to review this way of accessing the urgentcare area, as clients arriving in a state of distress may not take the time to read the sign or even notice thesign's instruction.

Patient assessment and access to diagnostics and physicians allow for patients to receive timely care. Allurgent care and EDs have 24/7 physician on-site coverage. This not only helps the urgent care areas, but alsothe units located at those sites for physician support. An evidence-based initiative on ordering ofcomputerized tomography (CT) scans during the night has resulted in ED physicians being able to orderdirectly without calling a radiologist. Time to care has improved, volumes have remained appropriate, andefficiencies have also been experienced.

The organization has made available access to specialists, either direct within a site, or via telephone forspecialties located in other sites in the organization. Telephone access to specialists from partnerorganizations is made available and is arranged via Criticall Ontario.

Processes for triage of adult and pediatric patients have been standardized across all sites and are enteredinto the e-triage tool. Clients report being instructed to make staff members aware of a change in theircondition during the triage process. Efforts to ensure client privacy are made at registration, and at theDouglas Memorial site this can be more challenging due to the size of the registration area and lack ofphysical division. This is more challenging when there are clinics operating and volumes are higher.

All departments have 24-hour access to laboratory (lab) testing with lab or point of care devices. Allemergency departments have access to diagnostic imaging (DI) 24 hours per day. Urgent care is on a call-backbasis.

Mechanisms are in place to allow accompanied transportation when required. The Niagara Health System isworking with its Emergency Medical Services (EMS) partners to adjust practice and protocols to the extent theskill level of EMS teams allows.

Observations during the on-site survey indicate that the information passed between EMS and ED staff, andfrom ED staff to receiving units on transfers is accurate and appropriate. At times, some process items aremissed such as patients being en route before notifying the receiving site has occurred. This can beproblematic when the receiving unit is over census.


organizations is made available and is arranged via Criticall Ontario.

QMENTUM PROGRAM

Processes for triage of adult and pediatric patients have been standardized across all sites and are enteredinto the e-triage tool. Clients report being instructed to make staff members aware of a change in theircondition during the triage process. Efforts to ensure client privacy are made at registration, and at theDouglas Memorial site this can be more challenging due to the size of the registration area and lack ofphysical division. This is more challenging when there are clinics operating and volumes are higher.

All departments have 24-hour access to laboratory (lab) testing with lab or point of care devices. Allemergency departments have access to diagnostic imaging (DI) 24 hours per day. Urgent care is on a call-backbasis.

Mechanisms are in place to allow accompanied transportation when required. The Niagara Health System isworking with its Emergency Medical Services (EMS) partners to adjust practice and protocols to the extent theskill level of EMS teams allows.

Observations during the on-site survey indicate that the information passed between EMS and ED staff, andfrom ED staff to receiving units on transfers is accurate and appropriate. At times, some process items aremissed such as patients being en route before notifying the receiving site has occurred. This can beproblematic when the receiving unit is over census.


Patient records are kept private and confidential. A standardized triage system is used across all sites. Waittime clocks are maintained, allowing the public to see the wait times in the emergency department (ED) andurgent care waiting rooms, as well as via the external Niagara Health System (NHS) website. There is an EDwait time tracker. In-patient units are able to electronically see the number of admissions and thus, knowwhen they are at risk of passing the standard time line and can help by “pulling” patients into their units.

Multiple order sets have been created and are standardized across all EDs. Evidence-based protocols for carehave been established. Hamilton Health Science’s expertise is drawn upon. As NHS becomes more involved inclinical academics, new opportunities for research are planned for the future, and there is a great deal ofexcitement as a result.


Teams are focused on providing a safe and quality patient-focused care experience. Safe practices such astwo patient identification, falls assessment, and handwashing have become the norm. These were observedduring the on-site survey and reported during all client and family interactions.

Staff members are fully knowledgeable in how, when and why to enter events into the incident reportingsystem. They state safety issues are discussed at unit huddles and solutions are developed collaboratively.

The organization is measuring a number of indicators including: length of stay in the emergency department(ED) for admitted patients, time to physician assessment, ambulance off-load times, left without being seen,patient complaints, admission rates, time to treatment for things like sepsis, and falls. These topics arediscussed at program committee meetings and during rhythm rounds.


QMENTUM PROGRAM


The organization is not responsible for the organ and tissue program. This service is led by an externalpartner. The organization has established strong linkages with this partner. Policies are in place, staffmembers have received education, and potential donors are identified. Missed opportunities are tracked andreviewed.


QMENTUM PROGRAM

3.2.7 Standards Set: Infection Prevention and Control Standards - DirectService Provision


Priority Process: Infection Prevention and Control

The organization has an interdisciplinary committee to provide guidanceabout the IPC program.

2.4

The interdisciplinary committee regularly evaluates the program's structureand functions and makes improvements as needed.

2.5


Priority Process: Infection Prevention and Control

Currently, the Niagara Health System (NHS) infection prevention and control (IPAC) department includes ninestaff members and a manager. The majority of the staff members are certified. Those requiring certificationare in the process of obtaining such. Staff members come from a diversity of health care backgrounds. Allstaff members rotate at all sites.

A surveillance process is in place where all microbiological samples taken are monitored. Based on theresults, certain triggers are initiated to provide safety to visitors and staff. Appropriate therapy can then beinitiated. Select surveillance organisms are actively monitored. Policies and procedures are in place toprovide a safe work environment.

Infection prevention and control (IPAC) and environmental services work closely to ensure a safe physicalenvironment for all staff members and users of the facility. When outbreaks are identified, external partnerssuch as Public Health are informed. Processes are put in place, information is analyzed and quality and safetyimprovements are implemented. Specimens collected are sent to an external laboratory (lab) associated withHamilton Health Sciences. Turn around time utilizing this lab has significantly improved and is usually around24 hours. This has improved the times for initiating appropriate triggers and care paths. The IPAC staffmembers do daily rounds on all isolated patients.

Data are now collected for surgical site infections and infection rates related to joint replacements.

A robust hand-hygiene monitoring program is in place. Base lines have been established and audits are doneon a weekly basis. Alcohol hand-hygiene stations are strategically placed, with instructions posted. During anaudit, if an area is identified as falling below the benchmark, resources and education are then targetedtowards that area.

Policies and procedures are in place and regularly updated as required. They are standardized across thecorporation. The information is available electronically for all staff. Several performance evaluations havenot been done for several years, and this needs attention.

The program collaborates with Public Health, community partners and major teaching centres in Hamiltonand Toronto. Meetings are held at regular intervals where information is shared and best practices reviewed.

In 2011 a major clostridium difficile outbreak was identified. A review of the IPAC program, outbreakmanagement and environmental services ensued, and recommendations were made and implemented.Surveillance has improved and outbreak rates are significantly decreased.

Currently, the major challenge appears to be the recruitment of a physician to take the leadership initiativefor IPAC. Due to the inability to recruit this individual no formal IPAC committee is in place. The managerprepares a report for the directors. There are several layers that the report passes through before it is seenby senior administration. A process needs to be put in place to streamline the reporting process and to allowrequired changes to be implemented quickly.

A comprehensive screening tool has been developed to assess all clients presenting for services.

Policies and procedures are in place for handling contaminated laundry and waste.

A huddle board has been developed specific for the department. The quality indicators are in line with thestrategic plan. Base lines have been developed with quality indicators that are measurable.


QMENTUM PROGRAM

In 2011 a major clostridium difficile outbreak was identified. A review of the IPAC program, outbreakmanagement and environmental services ensued, and recommendations were made and implemented.Surveillance has improved and outbreak rates are significantly decreased.

Currently, the major challenge appears to be the recruitment of a physician to take the leadership initiativefor IPAC. Due to the inability to recruit this individual no formal IPAC committee is in place. The managerprepares a report for the directors. There are several layers that the report passes through before it is seenby senior administration. A process needs to be put in place to streamline the reporting process and to allowrequired changes to be implemented quickly.

A comprehensive screening tool has been developed to assess all clients presenting for services.

Policies and procedures are in place for handling contaminated laundry and waste.

A huddle board has been developed specific for the department. The quality indicators are in line with thestrategic plan. Base lines have been developed with quality indicators that are measurable.


QMENTUM PROGRAM

3.2.8 Standards Set: Long-Term Care Services - Direct Service Provision







The team follows the organization's process to evaluate resident requests tobring in or self-administer their medication, and monitors residents whoself-administer.

12.3







The complex care team uses the quality and safety whiteboard to document and advance its qualityimprovement initiatives. Staff members are engaged and they support the promotion of independence andsafety for their patients.


Regular, interactive interdisciplinary bullet rounds ensure that all patients are thoroughly reviewed regularlyby the team. The team displays the qualities of respectful interdisciplinary collaboration. Unfortunately, apharmacist was not in attendance at the rounds to assist in the medication utilization discussions. Staffmembers stated that the unit does not have a dedicated pharmacist and having one would be beneficial forthe interdisciplinary team.


The long-term care team provides the patients and their families with a comprehensive manual uponadmission. The manual's contents cover many components of care including patient and family roles andrights and responsibilities. The staff members work with patients and their families to identify and developprograms and activities that have meaning and value. These programs are well attended and both staffmembers and patients look forward to them.


programs and activities that have meaning and value. These programs are well attended and both staffmembers and patients look forward to them.

QMENTUM PROGRAM


Some of the Long-term Care standards do not apply to the surveyed LTC sites as they are providing complexcare services which do not align with the definition of long-term care services. The acuity level of the careprovided at those sites can involve a complex care plan including intravenous medication therapies. This canbe seen as more aligned with the practices on a general medicine unit.


The use of two patient identifiers presents some challenge when unique identifiers are not readily availableat the bedside. For example, the medication administration record or medication labels contain thisinformation and when they are not available, at minimum, the patient should be asked to provide their nameand birth date, which is then confirmed by viewing the information on the their bracelet. The organization isencouraged to ensure consistent application of the use of two identifiers by all staff.


QMENTUM PROGRAM

3.2.9 Standards Set: Medication Management Standards - Direct ServiceProvision



Unit dose oral medications remain in the manufacturer's or pharmacy'spackaging until they are administered.

17.4

Service providers document lot numbers and expiry dates for vaccinesadministered in the client record.

23.6



The Niagara Health System (NHS) has invested in the implementation of safer medication practices across allsites. All sites have been equipped with AcuDose dispensers to increase safety and provide better drugmonitoring.

Training and education is readily available online with education videos for all staff. As well, a regularpharmacy newsletter is circulated to share trends and information. New pharmacist positions have beencreated. There is a Medication Safety Pharmacist to focus on safe medication practices and improve qualityfor patients, and a Drug Utilization Evaluation position and Antimicrobial Stewardship pharmacist in place.

Medication reconciliation is an important priority for the NHS. A comprehensive roll-out plan has beendeveloped and all service areas are aware of the plan. Standard medication administration times have helpedimprove standardization across sites. It is notable that the NHS has made efforts to achieve the requiredorganizational safety practices of Accreditation Canada, such as antimicrobial stewardship, high-alertmedication, limiting and standardizing drugs such as heparin, narcotics and electrolytes. Doctors' order sheetshave the “Do Not Use” abbreviation list at the top of the form to increase awareness and decrease the use ofabbreviations when ordering medications.

A NHS-wide pharmacy and therapeutics committee is in place. For requests to add medications to theformulary, departments are able to provide a presentation outlining the rationale for the request.

There is a secure, scheduled courier service which provides timely delivery of medications to the NHS sites,with appropriate safeguards that are required for the transportation of medication including hazardousmedications.

Medications are stored appropriately in both the pharmacies and the client service areas however, somepharmacies and medication areas on units are crowded and potentially distracting in the hub of activity.

A large number of standard order sets have been created across the NHS, and these are approved by a centralcommittee. This is commendable as it will help decrease variation and improve safety for patients. Theincrease in nurse practitioners (NPs) has helped support thorough reviews of medications with patients andtheir families. The NPs have made significant contributions to the programs especially on the complex careunits.

The safe handling of medications is critical and there is concern that some intravenous (IV) preparation areasare in poor condition and require upgrading in the “non-St. Catharine” sites. If improvements are made, itwould be valuable to increase capacity to allow the preparation of sterile IV admixtures to reduce potentialerrors when IV medications are prepared on the nursing units.

Labelling has been standardized however, the size of labels may need to be adjusted to ensure safety whenmultiple labels are used on small mini-bags.

Unit-dose packaged products provide important safety information and opportunities when the intact packageis brought to the bedside. The package provides information that supports the nurse in the provision ofpatient education and the patient's right to refuse a medication. The organization is encouraged to reinforcebest medication administration techniques with staff.

The organization has approved a high-alert and an independent double check (IDC) policy. While staffmembers correctly indicated when an IDC was necessary, the process that they described was a secondcheck, not an independently conducted check. Additional education to increase awareness may contribute tosuccessfully sustaining these two policies.

During the on-site survey, it was identified that there was no policy or process for self-administeredmedications. The original vaccine consent form included a location for health care providers to document thelot number and expiry date. A recent revision of the form has removed this location/prompt. In addition, thepharmacy does not document 'lot and expiry' when dispensing. The organization is encouraged to explore amechanism that will allow for identification of patients impacted in the event of a recall or Health Canadanotification. Ideally, the mechanism should allow for centralized collection of this information.


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The safe handling of medications is critical and there is concern that some intravenous (IV) preparation areasare in poor condition and require upgrading in the “non-St. Catharine” sites. If improvements are made, itwould be valuable to increase capacity to allow the preparation of sterile IV admixtures to reduce potentialerrors when IV medications are prepared on the nursing units.

Labelling has been standardized however, the size of labels may need to be adjusted to ensure safety whenmultiple labels are used on small mini-bags.

Unit-dose packaged products provide important safety information and opportunities when the intact packageis brought to the bedside. The package provides information that supports the nurse in the provision ofpatient education and the patient's right to refuse a medication. The organization is encouraged to reinforcebest medication administration techniques with staff.

The organization has approved a high-alert and an independent double check (IDC) policy. While staffmembers correctly indicated when an IDC was necessary, the process that they described was a secondcheck, not an independently conducted check. Additional education to increase awareness may contribute tosuccessfully sustaining these two policies.

During the on-site survey, it was identified that there was no policy or process for self-administeredmedications. The original vaccine consent form included a location for health care providers to document thelot number and expiry date. A recent revision of the form has removed this location/prompt. In addition, thepharmacy does not document 'lot and expiry' when dispensing. The organization is encouraged to explore amechanism that will allow for identification of patients impacted in the event of a recall or Health Canadanotification. Ideally, the mechanism should allow for centralized collection of this information.


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3.2.10 Standards Set: Medicine Services - Direct Service Provision








7.6 ROP

7.6.4 The prescriber uses the Best Possible Medication History(BPMH) and the current medication orders to generate transferor discharge medication orders.

MAJOR


MAJOR


The team identifies its needs for new technology and information systems.13.1





The medicine/nephrology teams are engaged and committed to the services they provide to the patients inthe region. Consolidation of specialized programs such as stroke care has resulted in standardized bestpractice care for this patient group. The team meets and reviews the needs for this population and makesappropriate changes when required.

The medical/nephrology nursing and physician leadership work together to improve metrics and haveexperienced a significant reduction in fall rates across all medicine units at all sites visited during the survey.The nephrology team has experienced a significant increase in home dialysis rates and is meeting the OntarioRenal Network provincial target for this important indicator.

All teams at all sites are committed to daily huddles that enable alignment of goals to improve service. Thegoals are visible and staff members are clearly able to articulate change and improvements for this patientgroup.


goals are visible and staff members are clearly able to articulate change and improvements for this patientgroup.

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The interdisciplinary team is made up of a variety of disciplines including occupational therapy andphysiotherapy and members work closely with nursing staff members to enhance the care of this complexmedical group of patients. The team members understand their roles and responsibilities and are effective inthe coordination of services for this patient group.

The interdisciplinary team is well-established and engaged in daily bullet rounds and safety huddles with acomprehensive goal to improve quality, safety and ensure safe and effective discharge of patients.

Intravenous (IV) pump infusion training is provided during orientation and during ongoing education sessions.

The medicine teams are active participants and leaders in the implementation of Inter-professional educationrounds in partnership with the local colleges and universities. Performance reviews are completed regularly,with input from team leaders when required.


Medicine/nephrology staff members complete comprehensive assessments in a timely manner andcommunicate overall care needs to colleagues at daily bullet rounds. There is dedicated hourly rounding witha focus on the four "Ps", which ensures timely and appropriate assessment throughout the hospital stay.Standardized transfer of accountability is evident in all medicine and nephrology units at all sites.

The interdisciplinary team is committed to daily huddles and bullet rounds where important safety, qualityand risk information is reviewed. Indicators are altered based on importance and staff ideas forimprovement. Real-time data are available and meaningful to staff. There has been a significant reduction infall rates for this patient group. Use of patient whiteboards ensures that information is shared with patientsand their families. The focus on patient goals was evident during the on-site interviews related to the careexperience.

Venous thrombo-embolism (VTE) prophylaxis is consistently implemented and part of all general admissionorder sets. Systems are in place to ensure audits and compliance with feedback to the team. There is astructured best practice approach using order sets, clinical pathways and benchmarking data for this complexpatient group. There is a patient centric-approach to medical care which includes patients and familymembers in all aspects of care.

During the survey some aspects of the best possible medication history (BPMH) was evident on discharge, andthe team is encouraged to continue implementation of all aspects of this required organizational practice(ROP).


Physician order entry is undergoing a trial on the medical units of the Niagara Health System. Order sets arewell ingrained for certain conditions and in addition, orders are being entered into the electronicenvironment for patient-specific needs.

when available. Nephrology is moving forward with clinical documentation that will support both thein-patient and out-patient aspects of the nephrology program. Plans for medical units to move to theelectronic chart were unclear at the time of the on-site survey.


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Fall prevention programs are ingrained into daily practice and changes have been made based on improvingthis metric significantly for all medical units and nephrology out-patient units.

Patient whiteboards ensure that information is shared with patents and their families and goals of care wereevident in all sites visited during the survey.

The interdisciplinary team is committed to daily huddles and safety briefings where important safety, qualityand risk information is discussed. Indicators are altered based on their importance for the patient populationand staff ideas. Real-time data are meaningful to all staff members working in this area.

The medicine and nephrology teams are encouraged to continue to develop written safety information thatpatients can take with them following discharge.


Paper-based charting forms have been updated and will ensure seamless transition to the electronic chartwhen available. Nephrology is moving forward with clinical documentation that will support both thein-patient and out-patient aspects of the nephrology program. Plans for medical units to move to theelectronic chart were unclear at the time of the on-site survey.

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3.2.11 Standards Set: Mental Health Services - Direct Service Provision














The mental health program is led by a team of truly committed individuals with a clear vision of what mentalhealth services should be and could be, and they are both true advocates and leaders for clients that aresuffering with mental illness. The forming of numerous partnerships internally and externally has createdfluidity and a seamless continuum of care for clients and their families. The team is continually reviewing itsservices versus the identified needs of its clients and is recognized for their creative approach.


There is a firm belief and commitment on the part of the leadership team of the mental health program toensure that services are rendered by a team of competent professionals. Their passion for the care of clientspresenting with mental illness is well demonstrated in their practice and in their response to the needs ofpatients. During the survey staff members readily identified the resources and training available to them toensure that they are current in their practice.

Leadership is responsive to the comments expressed by staff members regarding the staffing needs necessaryto address complex situations as well as their safety in the delivering of such care. The team has created aTeam Let's Chat (TLC) group with a group of volunteer nurse professionals to provide support such ascompassion fatigue to their fellow colleagues. The group members have been specifically trained to be ableto provide such support.


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The psychiatric emergency response team (PERT) is particularly proud of the pivotal role it plays in the careof patients presenting to the emergency department (ED) with a compromised condition. The importance ofcommunication with the numerous community and internal partners is considered key to a good assessmentof the client.

As a result of adjustments made in the handover of clients arriving in the ED accompanied by the police, thedelay in handover has been cut drastically. This has resulted in improved and collaborative workingrelationships with the police services.

Comprehensive transfer of information at all transition points is key to a successful episode of care for theclient. The team has also instituted what it describes as 'warm' transfers to ensure safe transition to the nextlevel of care. The team is commended for the numerous programs it has implemented to address themultitude of needs ranging from the pediatric population with the school program to the support groups forthe adult population.

The team is particularly proud of its transition to independent living program (TIL) which eases the return toindependent living and helping in the success of the transition after a long hospitalization period.

The team is commended for its successful implementation of the medication reconciliation process.


The team is commended for its rigorous approach when implementing new programs or services. Theapproach ensures that programs/services are evidence-based and recognized as best practice. The team isengaged in research and is working in close collaboration with other partners to advance practice and toensure patient/client needs are addressed. The nurse educator plays a key role in ensuring that practice iscurrent.


In identifying and implementing the numerous programs, a focus on process or clinical outcomes is at thecentre of the discussion. The programs implemented are evidence based. The team is proud of its researchproject on nurses' perception of pod nursing which is led by the nurse educator.


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3.2.12 Standards Set: Obstetrics Services - Direct Service Provision








9.6 ROP

9.6.4 The prescriber uses the Best Possible Medication History(BPMH) and the current medication orders to generate transferor discharge medication orders.

MAJOR


MAJOR


The team identifies its needs for new technology and information systems.16.1





A merger of three community hospital pediatric/obstetrics departments led to an established regionalamalgamation at the St.Catharines site. This has led to a strong culture of improvement and patient safetyfor both services. The obstetrics service sees more than 2700 newborn deliveries per year by midwives andobstetricians. The medical leadership is strong and recruitment for obstetricians continues. There are now 10pediatricians, with the successful recruitment of three recently. There is regional chief and chair,department of pediatrics.

The medical and nursing leadership work together to improve metrics and are below the provincial average inmany areas of practice. The team is committed to daily huddles that enable alignment of goals to improveservice. The goals are visible and staff members are clearly able to articulate improvements made sinceimplementation of this change.


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Since 2013, pregnant women planning to give birth at the Niagara Health System have had their babies at thenew St. Catharines site. The obstetrics service has a team that provides care which crosses to cover triage,labour and delivery and cesarean section deliveries and post-partum care in a new unit.

Leadership has worked diligently to ensure appropriate orientation and training to this specializedenvironment. A partnership with a local college ensured appropriate training for the nurses working in thetwo operating suites for cesarean sections. All nurses are certified in pediatric advanced life support andneonatal respiratory care. The pediatric unit has a part-time child life specialist that provides teaching andtherapy for the children. The pediatric unit has a clinical pharmacist available two days per week, withparticipation in rounds and provision of medication management support.

There are a large number of trainees and students in both areas such as family practice residents, physicianassistants, pediatric residents and fellows, as well as nursing students. The collaboration with McMasterUniversity and bringing academic pediatrics to the St. Catharines site has been perceived very positively.

Patients are cared for in a state-of-the-art facility by health care providers that are experts in maternity,newborn and women’s health care.


Since 2013, pregnant women planning to give birth at the Niagara Health System have had their babies at thenew St. Catharines site. Care is provided in a state-of-the-art facility by health care providers that areexperts in maternity, newborn and women’s health care. Birthing suites offer safe new mother and baby careand are a model for other hospitals.

The interdisciplinary team is committed to daily huddles and bullet rounds where important safety, qualityand risk information is reviewed. Indicators are altered based on importance and staff ideas forimprovement. Real-time data are available and meaningful to staff. All team members readily identifybarriers and make changes to improve patient care.

There is a structured best practice approach to ensuring maternal and fetal health assessments from the timeof admission until labour and delivery. There is a patient centric-approach to mother and child care thatincludes parent and family members in all aspects of care. Discharge follow-up telephone calls take place anddischarge arrangements include public health to determine high risk or high needs patients for follow-up inthe community.

The Infant Loss team has done significant work to ensure maximum support for those undergoing loss. Theteam has a variety of interdisciplinary staff members and the forget-me-not program is very patient centred.

In pediatrics, it is a challenge to have four mental health beds as part of the unit, as there is risk in the mixof patients/ages/conditions. As well, there are considerations regarding patient watch and securityrequirements in terms of resource use. A pediatric rapid assessment clinic has been established to provide analternative to hospital admissions. There is a perinatal bereavement committee and infant loss teamavailable in the special care nursery. Quality improvements have been made in hyper bilirubinemia in termand late pre-term infants during the past year.

Some aspects of best possible medication history (BPMH) is evident on discharge and the team is encouragedto continue implementation of all aspects of this required organizational practice (ROP).


to continue implementation of all aspects of this required organizational practice (ROP).

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For obstetrics, pediatrics and the special care nursery, single rooms create more privacy and confidentialityfor patients and their families. There are a number of best practice guidelines in place in all areas of theprogram. Order sets have been developed for a number of common conditions to standardize care. Transferof accountability (TOA) is used to ensure safety in patient transfers. A pediatric procedural sedation record iscurrently in development.

Paper-based charting forms have been updated, and will ensure seamless transition to the electronic chartwhen it is available. Plans to the electronic chart in this environment were unclear at the time of the on-sitesurvey.


The team reports and tracks various indicators required for the Local Health Integrated Network (LHIN) andBetter Outcomes Registry and Network (BORN). Significant improvements have been achieved for numerousindicators. As a member of the managing obstetrical risk efficiently (MORE ob) program the team has donesignificant education with the team on high-risk activities in the past three years.

For pediatrics and special care nursery, best practice information and education are supported with theincrease in pediatricians and expectations of the staff. Based on evaluation and feedback, the fallsprevention strategy has been customized for the pediatric and special care nursery populations.

All units utilize huddle boards and patient room white boards to improve quality and safety related to keyindicators such as patient falls, medication errors and obstetric-specific performance measures.


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3.2.13 Standards Set: Organ and Tissue Donation Standards for DeceasedDonors - Direct Service Provision
















An organ and tissue committee is in place which meets quarterly. The cases are reviewed and anyrecommendations or improvements are forwarded to the respective committees. The organization has adonation physician identified, and this physician co-chairs the committee. The committee members areenthusiastic and engaged. There is representation from many allied and primary health disciplines. Atransplant coordinator is available 24/7.


Many of the policies and procedures have been developed by Trillium Gift of Life physicians and staff. Theseresources are readily available via the transplant coordinator. The interdisciplinary team functionscollaboratively to provide a seamless process for initiating the organ procurement process.


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Information collection has become standardized and is consistently updated.


A unique identifier is assigned to all donors. This is available via the Trillium portal, with access restricted tothe transplant coordinator.


No specific comments are identified.


The organization is actively involved in the transplant process. There is active collaboration with Trillium Giftof Life Network. A transplant coordinator is available in the organization. All processes and steps aremanaged by Trillium. The organization's role is simply to identify the potential donors.

Noted strengths are: engaged, enthusiastic, and extremely well-trained staff members committed to patientwell being; excellent patient documentation and strong commitment to identifying potential donors, andstrong leadership.


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3.2.14 Standards Set: Point-of-Care Testing - Direct Service Provision


Priority Process: Point-of-care Testing Services



Priority Process: Point-of-care Testing Services

Point-of-care testing (POCT) is done in collaboration with nursing and laboratories, and it assures timelyintervention, and has significantly reduced wait times in obtaining results for specific tests in the smallercentres that offer urgent care. The on-site conversation with staff members that perform POCT revealed thebenefit of POCT, especially at times of increased occupancy.


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3.2.15 Standards Set: Substance Abuse and Problem Gambling Services -Direct Service Provision














Based on the changing needs of the clients presenting with both mental illness and issues with substanceabuse, the leadership team has implemented a concurrent program, which is based on leading practices inother jurisdictions and in partnership with the withdrawal management program.

The team is responsive to demand, and to urgent situations, and will open surge beds on an as needs basis. Aswas evidenced in the mental health program, the team is responsive to the needs of the clients in itsimmediate community, but also stretches province wide. Despite receiving insufficient funding coming from adifferent source the required professionals and workers needed to meet the client needs are nonethelessprovided.

Clinicians with a particular passion and interest in Hepatitis C and eating disorders have spearheaded thecreation of specific programs and activities for these clients.


Services and programs for clients are provided by a dedicated team of highly competent staff. The leadershipteam is attentive to the expressed training and safety needs and concerns of staff. Evidence of this is seen inthe recent changes made to the coverage of the intake area, from a sole person completing this function on apermanent basis to a rotational basis which involves several nurses.


permanent basis to a rotational basis which involves several nurses.

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Meeting the needs of the clients is the over arching concern of the team and it will do what needs to be doneto ensure that these are met and that there are no gaps in the continuity of care. Staff flexibility in providingservices is evident in as much as client and staff safety is assured.


There is a culture of evidence-based practice in the substance abuse program. Client and disorder-specificprograms such as the one for women as well as the one for eating disorders is based on literature review andbest practice.


Quality performance and identification and monitoring of quality indicators is well-understood andimplemented by the team. The team is encouraged to pursue its work in the monitoring of identifiedindicators in its goal of ensuring services provided and programs running meet the identified goals.


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3.2.16 Standards Set: Transfusion Services - Direct Service Provision


Priority Process: Transfusion Services



Priority Process: Transfusion Services

The on-site opportunity to observe the transfusion process from start to finish confirms there is strictadherence to all standards related to the transfusion process, and in an efficient, safe and timely manner.The continued collaborative work of the transfusion committee has provided a forum for reviewing all aspectsof transfusion services including education for clients and nursing staff. The team ensures that practice is themost current practice, and that all team members comply with all standard operating procedures.


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3.2.17 Priority Process: Surgical Procedures

Delivering safe surgical care, including preoperative preparation, operating room procedures, postoperativerecovery, and discharge


Standards Set: Perioperative Services and Invasive Procedures Standards

The preoperative assessment includes a discussion with the client aboutpostoperative pain management options and preferences.

8.7

The preoperative assessment includes processes to evaluate risk ofpostoperative nausea and vomiting (PONV).

8.8


Currently, the surgical program is spread over three sites. Corporate chiefs for surgery and anesthesia are inplace. A corporate nursing director is in place with site leaders. Both regulated and non-regulatedprofessionals work in this area. Nurses and registered practical nurses (RPNs) are required to haveappropriate post secondary education. They undergo a comprehensive orientation program. Educationprograms occur monthly for all staff. Skills days are organized on a yearly basis and all appropriate staffmembers are expected to attend. Registered nurse first-assists are utilized.

Currently, the St Catharines staff members are working in a new facility, and they had input to the design ofthe surgical area. The design has improved patient flow and safety. The dirty and clean areas are nowseparated. Clean storage is now enhanced. This has resulted in improved communication with central sterilereprocessing (CSR), improved patient flow and safety. Privacy has now improved. At the Niagara Falls site alldeficiencies identified in the last Accreditation survey report have been rectified. There now are separateareas for storage of clean supplies. This initiative was done in co-operation with infection prevention andcontrol (IPAC) staff.

Consolidation of some services has occurred. All cataracts are now done at the Welland site. On call fororthopedics consolidates call to either Welland or Niagara on weekends. Care for orthopedic patients hasbeen standardized. Efficiency and care have improved. This has allowed significant savings which arereinvested into the program.

The surgical program has developed its own huddle board with quality initiatives specific to the program.Each of the sites has developed their own indicators, with some being common to all sites. These are in linewith the corporate strategic plan. The indicators are measurable and provide useful information to allowchanges to be implemented.

A comprehensive pre-operative package has been developed. All patients scheduled for elective surgery areexpected to attend the pre-operative assessment clinic. The broncho pulmonary malformations (BPMs) isgenerated here, and the patients general medical health and status documented. Any additionalinvestigations and consultations are done at this time. The consent is verified and any education regardingthe procedure is undertaken. An on-site review of charts showed that assessment for post operative nauseaand vomiting (PONV), and post-op pain was not being documented. Transfer of information throughout thepatient surgical journey remains standardized and verifiable. It is suggested that the patient post-op painmanagement and PONV assessment be done and documented at some point in their surgical journey. Thepre-operative package has been standardized for all sites.

It was observed that pre-op antibiotics were prepared and mixed by staff members in the operating room(OR) or in day surgery. Pre-mixed antibiotics are available commercially or could be prepared under sterileconditions by pharmacy. Having this ability would eliminate errors and problems related with mixing. Patientsafety would be improved.

Patients are prepped in the surgical unit. All patients are expected to wash with a disinfectantpre-operatively. The IV is started and a warming blanket applied to patients undergoing major procedures.The assessment from the pre-op clinic is reviewed.

Care pathways and standardized order sets have been developed for some of the quality-based practice (QBP)procedures. This has allowed for standardization of care to occur. Currently, standardized order sets and carepathways are being developed for other procedures.

The PICIS smart tracker allows family members to track their family member's journey in the surgical process.

Cancellations rarely occur. All day surgery patients are contacted the day after surgery. Any concerns orquestions are answered and the patient experience is documented.

The St. Catharines surgical area is currently implementing an evidence-based staffing model. This is beingdone in collaboration with other centres. This will help to prevent burnout and stress of the nursing staff. Atthe other sites, patient assignments are done on the basis of patient complexity. New hires undergo acomprehensive orientation program on arrival to the surgical area. Regular staff education programs areorganized, and staff members are encouraged to proceed with additional education.

Patient satisfaction surveys have not been carried out specific to the surgical in-patient unit. Opportunitiesfor improvement include the need to continue the work to develop new standardized order sets; developclear documentation for venous thrombo embolism (VTE) prophylaxis, and to look at having pre-operativeantibiotics pre-mixed by pharmacy or supplied by an external provider.


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patient surgical journey remains standardized and verifiable. It is suggested that the patient post-op painmanagement and PONV assessment be done and documented at some point in their surgical journey. Thepre-operative package has been standardized for all sites.

It was observed that pre-op antibiotics were prepared and mixed by staff members in the operating room(OR) or in day surgery. Pre-mixed antibiotics are available commercially or could be prepared under sterileconditions by pharmacy. Having this ability would eliminate errors and problems related with mixing. Patientsafety would be improved.

Patients are prepped in the surgical unit. All patients are expected to wash with a disinfectantpre-operatively. The IV is started and a warming blanket applied to patients undergoing major procedures.The assessment from the pre-op clinic is reviewed.

Care pathways and standardized order sets have been developed for some of the quality-based practice (QBP)procedures. This has allowed for standardization of care to occur. Currently, standardized order sets and carepathways are being developed for other procedures.

The PICIS smart tracker allows family members to track their family member's journey in the surgical process.

Cancellations rarely occur. All day surgery patients are contacted the day after surgery. Any concerns orquestions are answered and the patient experience is documented.

The St. Catharines surgical area is currently implementing an evidence-based staffing model. This is beingdone in collaboration with other centres. This will help to prevent burnout and stress of the nursing staff. Atthe other sites, patient assignments are done on the basis of patient complexity. New hires undergo acomprehensive orientation program on arrival to the surgical area. Regular staff education programs areorganized, and staff members are encouraged to proceed with additional education.

Patient satisfaction surveys have not been carried out specific to the surgical in-patient unit. Opportunitiesfor improvement include the need to continue the work to develop new standardized order sets; developclear documentation for venous thrombo embolism (VTE) prophylaxis, and to look at having pre-operativeantibiotics pre-mixed by pharmacy or supplied by an external provider.


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Instrument ResultsSection 4

As part of Qmentum, organizations administer instruments. Qmentum includes three instruments (orquestionnaires) that measure governance functioning, patient safety culture, and quality of worklife. They arecompleted by a representative sample of clients, staff, senior leaders, board members, and otherstakeholders.

4.1 Governance Functioning Tool

The Governance Functioning Tool enables members of the governing body to assess board structures andprocesses, provide their perceptions and opinions, and identify priorities for action. It does this by askingquestions about:

• Board composition and membership• Scope of authority (roles and responsibilities)• Meeting processes• Evaluation of performance

Accreditation Canada provided the organization with detailed results from its Governance Functioning Tool priorto the on-site survey through the client organization portal. The organization then had the opportunity to addresschallenging areas.

• Data collection period: March 19, 2015 to April 6, 2015

• Number of responses: 10

Governance Functioning Tool Results

% Disagree % Neutral % Agree

Organization Organization Organization

* CanadianAverage

%Agree

1 We regularly review, understand, and ensurecompliance with applicable laws, legislation andregulations.

0 0 100 93

2 Governance policies and procedures that define ourrole and responsibilities are well-documented andconsistently followed.

0 0 100 96

3 We have sub-committees that have clearly-definedroles and responsibilities.

0 0 100 97

4 Our roles and responsibilities are clearly identifiedand distinguished from those delegated to the CEOand/or senior management. We do not becomeoverly involved in management issues.

0 0 100 94

5 We each receive orientation that helps us tounderstand the organization and its issues, andsupports high-quality decisionmaking.

0 0 100 93

Instrument Results 73Accreditation Report

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* CanadianAverage

%Agree

6 Disagreements are viewed as a search for solutionsrather than a “win/lose”.

0 0 100 95

7 Our meetings are held frequently enough to makesure we are able to make timely decisions.

0 0 100 97

8 Individual members understand and carry out theirlegal duties, roles and responsibilities, includingsub-committee work (as applicable).

0 0 100 97

9 Members come to meetings prepared to engage inmeaningful discussion and thoughtfuldecision-making.

0 10 90 94

10 Our governance processes make sure that everyoneparticipates in decision-making.

0 20 80 95

11 Individual members are actively involved inpolicy-making and strategic planning.

0 20 80 90

12 The composition of our governing body contributesto high governance and leadership performance.

0 0 100 93

13 Our governing body’s dynamics enable groupdialogue and discussion. Individual members ask forand listen to one another’s ideas and input.

0 0 100 96

14 Our ongoing education and professional developmentis encouraged.

0 0 100 90

15 Working relationships among individual members andcommittees are positive.

0 0 100 97

16 We have a process to set bylaws and corporatepolicies.

0 0 100 96

17 Our bylaws and corporate policies coverconfidentiality and conflict of interest.

0 0 100 98

18 We formally evaluate our own performance on aregular basis.

0 0 100 83

19 We benchmark our performance against othersimilar organizations and/or national standards.

0 13 88 71

20 Contributions of individual members are reviewedregularly.

0 10 90 66


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* CanadianAverage

%Agree

21 As a team, we regularly review how we functiontogether and how our governance processes could beimproved.

0 0 100 79

22 There is a process for improving individualeffectiveness when non-performance is an issue.

0 30 70 62

23 We regularly identify areas for improvement andengage in our own quality improvement activities.

0 10 90 79

24 As a governing body, we annually release a formalstatement of our achievements that is shared withthe organization’s staff as well as external partnersand the community.

0 29 71 81

25 As individual members, we receive adequatefeedback about our contribution to the governingbody.

0 11 89 69

26 Our chair has clear roles and responsibilities andruns the governing body effectively.

0 0 100 96

27 We receive ongoing education on how to interpretinformation on quality and patient safetyperformance.

0 0 100 90

28 As a governing body, we oversee the development ofthe organization's strategic plan.

0 0 100 96

29 As a governing body, we hear stories about clientsthat experienced harm during care.

20 0 80 88

30 The performance measures we track as a governingbody give us a good understanding of organizationalperformance.

0 0 100 95

31 We actively recruit, recommend and/or select newmembers based on needs for particular skills,background, and experience.

0 0 100 91

32 We have explicit criteria to recruit and select newmembers.

0 0 100 87

33 Our renewal cycle is appropriately managed toensure continuity on the governing body.

0 0 100 94


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* CanadianAverage

%Agree

34 The composition of our governing body allows us tomeet stakeholder and community needs.

0 0 100 93

35 Clear written policies define term lengths and limitsfor individual members, as well as compensation.

0 0 100 95

36 We review our own structure, including size andsubcommittee structure.

0 0 100 91

37 We have a process to elect or appoint our chair. 0 11 89 93

*Canadian average: Percentage of Accreditation Canada client organizations that completed the instrumentfrom January to June, 2015 and agreed with the instrument items.


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4.2 Canadian Patient Safety Culture Survey Tool

Organizational culture is widely recognized as a significant driver in changing behavior and expectations in orderto increase safety within organizations. A key step in this process is the ability to measure the presence anddegree of safety culture. This is why Accreditation Canada provides organizations with the Patient Safety CultureTool, an evidence-informed questionnaire that provides insight into staff perceptions of patient safety. This toolgives organizations an overall patient safety grade and measures a number of dimensions of patient safetyculture.

Results from the Patient Safety Culture Tool allow the organization to identify strengths and areas forimprovement in a number of areas related to patient safety and worklife.

Accreditation Canada provided the organization with detailed results from its Patient Safety Culture Tool prior tothe on-site survey through the client organization portal. The organization then had the opportunity to addressareas for improvement. During the on-site survey, surveyors reviewed progress made in those areas.

• Data collection period: May 26, 2014 to July 20, 2014

• Number of responses: 954

• Minimum responses rate (based on the number of eligible employees): 342


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0

10

20

30

40

50

60

70

80

90

100

Perc

enta

ge

Posi

tive

(%)

Organizational(senior)

leadershipsupport for

safety

Unit learningculture

Supervisoryleadership for

safety

Enabling OpenCommunicatio

n I:judgment-freeenvironment

Enabling OpenCommunicatio

n II: jobrepercussions

of error

58%

Incidentfollow up

Stand-aloneitems

60% 70% 47% 28% 57% 50%

67% 65% 77% 55% 33% 69% 64%

*Canadian average: Percentage of Accreditation Canada client organizations that completed the instrumentfrom July to December, 2014 and agreed with the instrument items.

OverallPerceptions ofClient Safety

62%

52%

* Canadian Average

Niagara Health System

Legend

Canadian Patient Safety Culture Survey Tool: Results by Patient Safety Culture Dimension


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4.3 Worklife Pulse

Accreditation Canada helps organizations create high quality workplaces that support workforce wellbeing andperformance. This is why Accreditation Canada provides organizations with the Worklife Pulse Tool, anevidence-informed questionnaire that takes a snapshot of the quality of worklife.

Organizations can use results from the Worklife Pulse Tool to identify strengths and gaps in the quality ofworklife, engage stakeholders in discussions of opportunities for improvement, plan interventions to improve thequality of worklife and develop a clearer understanding of how quality of worklife influences the organization'scapacity to meet its strategic goals. By taking action to improve the determinants of worklife measured in theWorklife Pulse tool, organizations can improve outcomes.

The organization used an approved substitute tool for measuring quality of Worklife. The organization hasprovided Accreditation Canada with results from its substitute tool and had the opportunity to identify strengthsand address areas for improvement. During the on-site survey, surveyors reviewed actions the organization hastaken.


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Measuring client experience in a consistent, formal way provides organizations with information they

can use to enhance client-centred services, increase client engagement, and inform quality

improvement initiatives.

Prior to the on-site survey, the organization conducted a client experience survey that addressed the

following dimensions:

Respecting client values, expressed needs and preferences,including respecting client rights,

cultural values, and preferences; ensuring informed consent and shared decision-making; and

encouraging active participation in care planning and service delivery.

Sharing information, communication, and education,including providing the information that

people want, ensuring open and transparent communication, and educating clients and their

families about the health issues.

Coordinating and integrating services across boundaries,including accessing services,

providing continuous service across the continuum, and preparing clients for discharge or

transition.

Enhancing quality of life in the care environment and in activities of daily living,including

providing physical comfort, pain management, and emotional and spiritual support and

counselling.

The organization then had the chance to address opportunities for improvement and discuss related

initiatives with surveyors during the on-site survey.

4.4 Client Experience Tool

Client Experience Program Requirement

Conducted a client experience survey using a survey tool and approach thatmeets accreditation program requirements

Unmet

Provided a client experience survey report(s) to Accreditation Canada Met


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QmentumAppendix A

Health care accreditation contributes to quality improvement and patient safety by enabling a healthorganization to regularly and consistently assess and improve its services. Accreditation Canada's Qmentumaccreditation program offers a customized process aligned with each client organization's needs and priorities.

As part of the Qmentum accreditation process, client organizations complete self-assessment questionnaires,submit performance measure data, and undergo an on-site survey during which trained peer surveyors assess theirservices against national standards. The surveyor team provides preliminary results to the organization at the endof the on-site survey. Accreditation Canada reviews these results and issues the Accreditation Report within 10business days.

An important adjunct to the Accreditation Report is the online Quality Performance Roadmap, available to clientorganizations through their portal. The organization uses the information in the Roadmap in conjunction with theAccreditation Report to ensure that it develops comprehensive action plans.

Throughout the four-year cycle, Accreditation Canada provides ongoing liaison and support to help theorganization address issues, develop action plans, and monitor progress.

Following the on-site survey, the organization uses the information in its Accreditation Report and QualityPerformance Roadmap to develop action plans to address areas identified as needing improvement. Theorganization provides Accreditation Canada with evidence of the actions it has taken to address these requiredfollow ups.

Five months after the on-site survey, Accreditation Canada evaluates the evidence submitted by the organization.If the evidence shows that a sufficient percentage of previously unmet criteria are now met, a new accreditationdecision that reflects the organization's progress may be issued.

Evidence Review and Ongoing Improvement

Action Planning

Qmentum 81Accreditation Report

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Priority ProcessesAppendix B

Priority processes associated with system-wide standards

Priority Process Description

Communication Communicating effectively at all levels of the organization and with externalstakeholders.

Emergency Preparedness Planning for and managing emergencies, disasters, or other aspects of publicsafety.

Governance Meeting the demands for excellence in governance practice.

Human Capital Developing the human resource capacity to deliver safe, high quality services.

Integrated QualityManagement

Using a proactive, systematic, and ongoing process to manage and integratequality and achieve organizational goals and objectives.

Medical Devices andEquipment

Obtaining and maintaining machinery and technologies used to diagnose andtreat health problems.

Patient Flow Assessing the smooth and timely movement of clients and families throughservice settings.

Physical Environment Providing appropriate and safe structures and facilities to achieve theorganization’s mission, vision, and goals.

Planning and Service Design Developing and implementing infrastructure, programs, and services to meetthe needs of the populations and communities served.

Principle-based Care andDecision Making

Identifying and making decisions about ethical dilemmas and problems.

Resource Management Monitoring, administering, and integrating activities related to the allocationand use of resources.

Priority processes associated with population-specific standards


Chronic Disease Management Integrating and coordinating services across the continuum of care forpopulations with chronic conditions

Population Health andWellness

Promoting and protecting the health of the populations and communitiesserved through leadership, partnership, and innovation.

Priority Processes 82Accreditation Report

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Priority processes associated with service excellence standards


Blood Services Handling blood and blood components safely, including donor selection, bloodcollection, and transfusions

Clinical Leadership Providing leadership and direction to teams providing services.

Competency Developing a skilled, knowledgeable, interdisciplinary team that can manageand deliver effective programs and services.

Decision Support Maintaining efficient, secure information systems to support effective servicedelivery.

Diagnostic Services: Imaging Ensuring the availability of diagnostic imaging services to assist medicalprofessionals in diagnosing and monitoring health conditions

Diagnostic Services:Laboratory

Ensuring the availability of laboratory services to assist medical professionalsin diagnosing and monitoring health conditions

Episode of Care Partnering with clients and families to provide client-centred servicesthroughout the health care encounter.

Impact on Outcomes Using evidence and quality improvement measures to evaluate and improvesafety and quality of services.

Infection Prevention andControl

Implementing measures to prevent and reduce the acquisition andtransmission of infection among staff, service providers, clients, and families

Living Organ Donation Living organ donation services provided by supporting potential living donorsin making informed decisions, to donor suitability testing, and carrying outliving organ donation procedures.

Medication Management Using interdisciplinary teams to manage the provision of medication to clients

Organ and Tissue Donation Providing organ and/or tissue donation services, from identifying andmanaging potential donors to recovery.

Organ and Tissue Transplant Providing organ and/or tissue transplant service from initial assessment tofollow-up.

Point-of-care TestingServices

Using non-laboratory tests delivered at the point of care to determine thepresence of health problems

Primary Care ClinicalEncounter

Providing primary care in the clinical setting, including making primary careservices accessible, completing the encounter, and coordinating services


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Public Health Maintaining and improving the health of the population by supporting andimplementing policies and practices to prevent disease, and to assess,protect, and promote health.

Surgical Procedures Delivering safe surgical care, including preoperative preparation, operatingroom procedures, postoperative recovery, and discharge


Documents

Niagara Health System · Qmentum accreditation program. As part of this ongoing process of quality improvement, an on-site survey was conducted in November 2015. Information from